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Acknowledgements
The development of this document was supported by the United States Department of Health
and Human Services (HHS), Substance Abuse and Mental Health Services Administration
(SAMHSA), through Grant No. SMO59945 to Education Development Center, Inc., for the
Suicide Prevention Resource Center. Design and review were supported by Gallup, under Contract
No. HHS28300001T/HHS2832007000231, Ref No. 283-07-2301, SAMHSA, HHS.
Electronic Access
This publication may be downloaded or ordered at
www.surgeongeneral.gov/library/reports/national-strategy-suicide-prevention/index.html
or
www.actionallianceforsuicideprevention.org/NSSP
or
www.samhsa.gov/nssp
Suggested Citation
U.S. Department of Health and Human Services (HHS) Office of the Surgeon General
and National Action Alliance for Suicide Prevention. 2012 National Strategy for Suicide
Prevention: Goals and Objectives for Action. Washington, DC: HHS, September 2012.
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2012 NATIONAL STRATEGY FOR SUICIDE PREVENTION
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2012 NATIONAL STRATEGY FOR SUICIDE PREVENTION
As the Surgeon General, I want to help make Americans aware of the heavy burden suicide imposes on our
nation, and more importantly, do everything I can to help reduce the toll that suicide takes on America.
That is what this document is all about.
No matter where we live or what we do every day, each of us has a role in preventing suicide. Our actions
can make a difference. While a document alone will not prevent a single suicide, I hope that this document
will help spur and leverage all of our actions so we can make real progress now in preventing suicide. We
have no time to waste.
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2012 NATIONAL STRATEGY FOR SUICIDE PREVENTION
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2012 NATIONAL STRATEGY FOR SUICIDE PREVENTION
Dedication
To those who have lost their lives by suicide,
To all those who work tirelessly to prevent suicide and suicide attempts in our nation.
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Contents
Introduction ......................................................................................................... 10
Appendix A: ......................................................................................................... 75
National Strategy for Suicide Prevention Goals and Objectives for Action Summary List
Appendix B: ......................................................................................................... 81
Appendix C: ......................................................................................................... 94
Glossary
Acknowledgments............................................................................................... 157
References......................................................................................................... 164
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Introduction
Suicide is a serious public health problem that causes immeasurable pain, suffering, and loss to individuals,
families, and communities nationwide. Many people may be surprised to learn that suicide was one of the
top 10 causes of death in the United States in 2009.1 And death is only the tip of the iceberg. For every
person who dies by suicide, more than 30 others attempt suicide.2 Every suicide attempt and death affects
countless other individuals. Family members, friends, coworkers, and others in the community all suffer
the long-lasting consequences of suicidal behaviors.
Suicide places a heavy burden on the nation in terms of the
Key Facts: emotional suffering that families and communities experience as
Suicide is the 10th leading cause well as the economic costs associated with medical care and lost
of death, claiming more than productivity. And yet suicidal behaviors often continue to be met
twice as many lives each year as with silence and shame. These attitudes can be formidable barriers to
does homicide.1 providing care and support to individuals in crisis and to those who
have lost a loved one to suicide.
On average, between 2001
and 2009, more than 33,000 More than a decade has passed since Surgeon General David Satcher
Americans died each year as a broke the silence surrounding suicide in the United States by issuing
result of suicide, which is more The Surgeon General’s Call to Action to Prevent Suicide.5 Published
than 1 person every 15 minutes.1 in 1999, this landmark document introduced a blueprint for suicide
prevention and guided the development of the National Strategy
More than 8 million adults report for Suicide Prevention (National Strategy). Released in 2001, the
having serious thoughts of suicide National Strategy set forth an ambitious national agenda for suicide
in the past year, 2.5 million prevention consisting of 11 goals and 68 objectives.6
report making a suicide plan in
What has changed since the National Strategy was released in 2001?
the past year, and 1.1 million
Where have efforts been successful, and where is more work needed?
report a suicide attempt in the
What new findings from scientific research can help enhance suicide
past year.3
prevention efforts and improve the care provided to those who have
Almost 16 percent of students been affected by suicide? What lessons learned can help guide suicide
in grades 9 to 12 report having prevention efforts in the years to come?
seriously considered suicide,
To assess progress made to date and identify remaining challenges,
and 7.8 percent report having
the Substance Abuse and Mental Health Services Administration
attempted suicide one or more
(SAMHSA) commissioned the report Charting the Future of Suicide
times in the past 12 months.4
Prevention.7 Published in 2010, the report identified substantial
achievements in suicide prevention in the years following the release
of the National Strategy. Examples include the enactment of the
Garrett Lee Smith Memorial Act, the creation of the National Suicide Prevention Lifeline (800–273–
TALK/8255) and its partnership with the Veterans Crisis Line, and the establishment of the Suicide
Prevention Resource Center (SPRC). Other areas of progress include the increased training of clinicians
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and community members in the detection of suicide risk and appropriate response, and enhanced
communication and collaboration between the public and private sectors on suicide prevention. The
report also described remaining challenges and identified priority areas for action.
Informed by this assessment, the National Action Alliance for Suicide Prevention (Action Alliance), a
public-private partnership focused on advancing the National Strategy, formed an expert task force to
revise and update the National Strategy. This document is the product of that task force’s deliberations and
also reflects substantial input from individuals and organizations nationwide with an interest in suicide
prevention. The revised National Strategy is a call to action that is intended to guide suicide prevention
actions in the United States over the next decade.
The National Strategy includes 13 goals and 60 objectives that have been updated to reflect advances in
suicide prevention knowledge, research, and practice, as well as broader changes in society and health
care delivery that have created new opportunities for suicide prevention. Some of the major developments
addressed in the revised National Strategy include:
A better understanding of how suicide is related to mental illness, substance abuse, trauma, violence,
and other related issues;
New information on groups that may be at an increased risk for suicidal behaviors;
Increased knowledge of the types of interventions that may be most effective for suicide prevention; and
An increased recognition of the importance of implementing suicide prevention efforts in a
Because suicide is closely linked with mental illness,8 in the past, suicide prevention was often viewed as
an issue that mental health agencies and systems should address. However, the vast majority of persons
who may have a mental disorder do not engage in suicidal behaviors.9 Moreover, mental health is only one
of many factors that can influence suicide risk. For example, enhancing connectedness to others has been
identified as a strategy for preventing suicidal behaviors and other problems.10 All of us can play a role in
helping to make this protective factor more widely available.
Suicide prevention is not exclusively a mental health issue. It is a health issue that must be addressed at
many levels by different groups working together in a coordinated and synergistic way. Federal, state,
tribal, and local governments; health care systems, insurers, and clinicians; businesses; educational
institutions; community-based organizations; and family members, friends, and others—all have a role to
play in suicide prevention. The revised National Strategy reflects this understanding.
Suicide prevention efforts must involve a wide range of partners and draw on a diverse set of resources and
tools. The National Strategy seeks to do so by integrating suicide prevention into the mission, vision, and
work of a wide range of organizations and programs in a comprehensive and coordinated way.
A comprehensive approach to suicide prevention is described on pages 12 and 13. In this description, a person
who is struggling with depression and thoughts of suicide is given the services and support he or she needs
to recover from these challenges and regain a sense of complete physical, mental, emotional, and spiritual
health and well-being.
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Understanding Suicide
Although some people may perceive suicide as the act of a troubled person, it is a complex outcome
that is influenced by many factors. Individual characteristics may be important, but so are relationships
with family, peers, and others, and influences from the broader social, cultural, economic, and
physical environments.
There is no single path that will lead to suicide. Rather, throughout life, a combination of factors, such as a
serious mental illness, alcohol abuse, a painful loss, exposure to violence, or social isolation may increase
the risk of suicidal thoughts and behaviors.
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Key Terms
t Affected by suicide. All those who may feel the effect of suicidal behaviors, including those
bereaved by suicide, community members, and others.
t Behavioral health. A state of mental and emotional being and/or choices and actions that
affect wellness. Behavioral health problems include mental and substance use disorders
and suicide.
t Bereaved by suicide. Family members, friends, and others affected by the suicide of a loved
one (also referred to as survivors of suicide loss).
t Means. The instrument or object used to carry out a self-destructive act (e.g., chemicals,
medications, illicit drugs).
t Suicide. Death caused by self-directed injurious behavior with any intent to die as a result of
the behavior.
t Suicide attempt. A nonfatal, self-directed, potentially injurious behavior with any intent to
die as a result of the behavior. A suicide attempt may or may not result in injury.
These definitions reflect how these terms are used in the National Strategy for Suicide
Prevention. For more information, including detailed definitions used in suicide surveillance,
see the glossary in Appendix F.
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PROTECTIVE
FACTORS
RISK
FACTORS
Availability of lethal Few available sources of High conflict or violent Mental illness
means of suicide supportive relationships relationships
Substance abuse
Unsafe media portrayals Barriers to health care Family history of suicide
of suicide (e.g., lack of access to Previous suicide attempt
providers or medications,
prejudice) Impulsivity/aggression
Adapted from: Dahlberg LL, Krug EG. Violence—a global public health problem. In: Krug E, Dahlberg LL, Mercy JA, Zwi AB, Lozano R, eds.
World report on violence and health. Geneva, Switzerland: World Health Organization; 2002:1–56.
Suicide is closely linked with mental and substance use disorders13 and shares risk and protective factors with other
types of self-directed violence,14 interpersonal violence,15 and other related problems. As a result, efforts to reduce
the risk factors and to increase the protective factors for suicide are likely to also help prevent or reduce these and
other problems. For example, a comprehensive suicide prevention program implemented by the U.S. Air Force (see
box on page 21) was found to not only prevent suicide but also to reduce family violence and homicide. 16
___________________
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SOURCE: Death data are from the National Vital Statistics System operated by the National Center for Health Statistics, CDC.
Age-adjusted rates for 1950–2009 were obtained from WISQARS (www.cdc.gov/injury/wisqars).
The prevalence of suicide varies by region and state. Suicide rates are higher in the western part of the
country than in other regions (see map on page 17).1
Suicide rates are only part of the picture. Existing data indicate that many people think about suicide and
may also engage in suicidal behaviors. During 2008 and 2009, an estimated 8.3 million (annual average)
adults aged 18 years and older (3.7 percent of the adult U.S. population) reported having suicidal thoughts
in the past year.18 The prevalence of having suicidal thoughts ranged from 2.1 percent in Georgia to 6.8
percent in Utah. In addition, an estimated 1 million adults in the United States reported making a suicide
attempt in the past year.
Suicide-related thoughts and behaviors are also common among youth. According to the 2011 Youth Risk
Behavior Survey, more than 1 in 7 high school students nationwide reported having seriously considered
attempting suicide in the 12 months before the survey.4 In addition, 7.8 percent of students, or about 1 in
13 reported having attempted suicide in the past year.
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SOURCE: Death data are from the National Vital Statistics System operated by the National Center for Health Statistics, CDC.
Age-adjusted rates for 2009 were obtained from WISQARS (www.cdc.gov/injury/wisqars).
Many barriers make it difficult to know exactly how common suicidal behaviors are in the general
population and in particular subgroups. Suicides are often underreported, in part because it may be
difficult to determine intent. In some cases, existing data collection instruments may fail to include
questions that would help determine the prevalence of suicidal behaviors among particular groups. For
example, because death certificates do not indicate sexual orientation and gender identity, rates of deaths
by suicide in lesbian, gay, bisexual, and transgender (LGBT) populations are unknown. The quality of
some death investigations needs to improve. Additionally, in some states, key data sources such as death
certificates and medical examiner reports may not yet be linked. The National Violent Death Reporting
System (NVDRS)19 helps to address this limitation, but the system is currently available in only 18 states.
Data on the national prevalence of suicide are available from a related online system, Web-Based Injury
Statistics Query and Reporting System (WISQARS).20
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45
40
35
30
25
20
15
10
5
0
SOURCE: Death data are from the National Vital Statistics System operated by the National Center for Health Statistics, CDC.
Age-adjusted rates for 2009 were obtained from WISQARS (www.cdc.gov/injury/wisqars).
Although white men 75 years of age and older have the highest rates of suicide, most deaths from suicide
occur among white men in midlife, who make up a larger part of the population.1 Suicide rates among
young people 15–24 years of age are generally not higher than among adults. However, because young
people are less likely than older people to die from medical conditions such as heart disease and cancer,
suicide is one of the top three causes of death in this population, along with unintentional injuries and
homicides.1 Moreover, suicidal behaviors are particularly common among some subgroups of youth.
For example, it is estimated that 14 to 27 percent of American Indian/Alaska Native adolescents have
attempted suicide.21-23
Having a mental and/or a substance use disorder can greatly increase the risk for suicidal behaviors.13
Suicide rates are particularly high among individuals with mood disorders such as major depression and
bipolar disorders. Suicidal thoughts and/or behaviors are common among patients with bipolar disorders,
and suicide rates are estimated to be more than 25 times higher for these patients than among the general
population.24, 25 Another mental disorder that may increase the risk for suicide is schizophrenia. Suicide
has been estimated to occur in approximately 5 percent of patients with this disorder.26
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Alcohol and drug abuse are second only to mood disorders as the most frequent risk factors for suicidal
behaviors. In 2008, alcohol was a factor in approximately one-third of suicides reported in 16 states.27
Having both a substance use disorder and a mental disorder, particularly a mood disorder, also has been
found to increase suicide risk.28
Some medical conditions, including cancer and chronic diseases that impair physical function and/or lead
to chronic pain, also may increase the risk for suicidal behaviors.29 Research also suggests that engaging
in acts of self-injury may lead to suicide later in life.30 This has been found to be true in cases when the
self-injury involves the intent to die, as well as in cases when there is no suicidal intent (also referred to as
nonsuicidal self-injury, or NSSI).31
The more of these signs a person shows, the greater the risk of suicide. Warning signs are associated with
suicide but may not be what causes a suicide.
What To Do
If someone you know exhibits warning signs of suicide:
Do not leave the person alone;
Remove any objects that could be used in a suicide attempt;
Call the U.S. National Suicide Prevention Lifeline at 800–273–TALK/8255; and
Take the person to an emergency room or seek help from a medical or mental health professional.
Adapted from Recommendations for Reporting on Suicide website (www.reportingonsuicide.org.)
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Individuals in some settings, systems, and professions may be at an increased risk for suicidal thoughts
and/or behaviors compared to the general population. Suicide is often the most common cause of death
in secure justice settings.32 More than 400 suicides occur each year in local jails at a rate three times
greater than among the general population, and suicide is the third leading cause of death in prisons.33-35
In the past decade, increases in the rate of suicide among members of the U.S. Armed Forces has led to
the implementation of extensive prevention programs in all branches of the military. In addition, concern
about suicide among veterans has also led to extensive suicide prevention efforts. There is also concern
that youth in the foster care system may be at an increased risk for suicidal behaviors and other related
problems.36, 37 More research is needed to better understand suicide risk among this population and to
develop appropriate responses.
Other groups identified as having a higher risk for suicidal thoughts and/or behaviors than the general
population include LGBT populations38 and individuals who have been bereaved by suicide.39 For more
information on these and other groups, see Appendix D.
More research is needed to better understand why suicide rates may be particularly low among some
groups, such as African American women. In 2009, the suicide rate among black women aged 20–59
years was 2.77 per 100,000, the lowest rate among adults in this age range.1 It is possible that factors such
as greater social support, larger extended families, and deeper religious views against suicide may help
protect some groups from suicide. A better understanding of these and other protective factors would help
inform future suicide prevention efforts.
Preventing Suicide
Suicide prevention requires a combination of universal, selective, and indicated strategies.9 Universal
strategies target the entire population. Selective strategies are appropriate for subgroups that may be at
increased risk for suicidal behaviors. Indicated strategies are designed for individuals identified as having a
high risk for suicidal behaviors, including someone who has made a suicide attempt.
Just as suicide has no one single cause, there is no single prevention activity that will prevent suicide. To be
successful, prevention efforts must be comprehensive and coordinated across organizations and systems
at the national, state/territorial, tribal, and local levels. As with other health promotion efforts, suicide
prevention programs should be culturally attuned and locally relevant.
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Research has also helped clarify the link between early childhood adverse events and suicide later in
life, and of the role of connectedness in protecting individuals from a wide range of health problems,
including suicide.45 Efforts that promote overall health and that help build positive relationships can play
an important role in suicide prevention. As a result, suicide prevention must be integrated into the work
of a broad range of partners that provide programs and services in these areas. Suicide prevention is
everyone’s business.
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Two online resources—the National Registry of Evidence-Based Programs and Practices (NREPP)
and the Best Practices Registry (BPR)—are helping to disseminate these findings so they may be more
widely used. NREPP, a searchable online registry maintained by the Substance Abuse and Mental Health
Services Administration (SAMHSA), provides information on more than 220 interventions supporting
mental health promotion, substance abuse prevention, and mental health and substance abuse treatment.
BPR, a registry that focuses specifically on suicide prevention programs, is maintained by the national
Suicide Prevention Resource Center (SPRC) in collaboration with the American Foundation for Suicide
Prevention, with funding from SAMHSA.46 More information on these and other resources is included in
Appendix E.
SECRETARIAT NATIONAL
NATIONAL COUNCIL
COUNCIL FOR
FOR
SUICIDE
SUICIDE PREVENTION
ADVISORY GROUPS
PREVENTION
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In 2010, the Action Alliance created an expert task force dedicated to the National Strategy for Suicide
Prevention. The task force implemented a revision process that included the following sources of input:
Alliance website;
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For a list of the revised goals and
objectives, see Appendix A. A crosswalk
from the original to the revised list is provided in Appendix B.
The four strategic directions are interrelated and interactive, rather than stand alone areas. Several broad
themes are at the core of the National Strategy and are addressed across all four strategic directions (see
box on page 25).
Although some groups have higher rates of suicidal behaviors than others, the goals and objectives do
not focus on specific populations or settings. Rather, they are meant to be adapted to meet the distinctive
needs of each group, including new groups that may be identified in the future as being at an increased
risk for suicidal behaviors. Appendix D provides information on groups currently identified as having
increased suicide risk.
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and objectives to identify their own priority areas, thereby contributing to the full implementation of the
National Strategy.
A careful assessment of needs, resources, and opportunities can help guide the identification of priorities.
As an example, the Action Alliance conducted this type of assessment to identify its four priority areas
for 2012–14:
1. Integrating suicide prevention into health care reform and encouraging the adoption of similar
measures in the private sector;
2. Transforming health care systems to significantly reduce suicide;
3. Changing the public conversation about suicide and suicide prevention; and
4. Increasing the quality, timeliness, and usefulness of surveillance data regarding suicidal behaviors.
Each priority area is aligned with one or more National Strategy objectives (see table listing Action
Alliance priority areas for 2012–14 on page 27). For example, priority area 2—Transforming health care
systems to significantly reduce suicide—is closely linked with Objective 8.1—Promote the adoption of
“zero suicides” as an aspirational goal by health care and community support systems that provide services
and support to defined patient populations. Evidence from several system-level interventions conducted in
the United States as well as abroad (see box for lessons from the United Kingdom on page 28) suggests that
this type of approach has a tremendous potential for saving lives.
Several considerations helped guide the development of this action agenda.
Potential effect on suicide-related morbidity and mortality. Reducing the burden of suicide in the nation
is a key area of concern. The selection of priority areas must take into account the potential for saving
lives, preventing injury, and lowering the costs associated with suicidal behaviors. For example, because
the greatest numbers of suicide deaths occur among white men in midlife, efforts targeting this group
may have the greatest short-term effect on reducing the suicide rate. Similarly, efforts targeting high-risk
groups, such as persons who have attempted suicide, may have the potential to help lower suicide rates
more quickly than other strategies.
Existing opportunities for action. In selecting areas for action, it is important to take advantage of
existing programs, opportunities, and resources, including initiatives that are already underway and that
could be expanded or brought to scale in the short term. Examples include expanding the NVDRS system
to additional states and territories and promoting the adoption of system-level approaches to suicide
prevention and major depression that have been implemented by the U.S. Air Force16 and the Henry Ford
Health System,49 among others.
Availability of data for measuring progress. Assessing the availability of sources of data for measuring
progress is another key consideration. Although the surveillance of suicide-related data has improved
over the years, data may not yet be available to measure progress toward every objective in the National
Strategy. When data sources are not available, mechanisms for collecting the data must be put into place so
that progress can be measured and monitored in future years.
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Partners and roles. The 60 objectives included in the National Strategy address various areas, including
health promotion; treatment of high-risk individuals; care for those who have been bereaved by suicide;
and issues related to surveillance, research, and evaluation. The selection of priority objectives must take
into account existing organizations, agencies, or other groups that may be interested and able to contribute
to progress in specific areas. These partners may be willing to take on specific roles, such as serving as the
lead organization for a priority area or helping to collect data and measure progress.
These types of considerations may be useful to other groups as they identify their own priority areas for
action. Each group is encouraged to identify the objective(s) that are most relevant to the individuals
they serve, and where its actions are most likely to yield positive results. The sections that follow provide
examples of how different groups can help advance the goals and objectives in each of the National
Strategy’s four strategic directions.
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The National Strategy hopes to energize and sustain the efforts of those who already are engaged in suicide
prevention by demonstrating how their work is connected to a larger movement aimed at addressing
this serious problem. For those not yet engaged, the National Strategy identifies areas where their future
contributions can make a difference in advancing suicide prevention in their communities. For those
experiencing a suicide loss or struggling with thoughts of suicide, the National Strategy provides ideas on
how to turn pain into recovery and hope for a better future.
Making this vision a reality requires all members of our communities to be involved. Each and every
one of us has a role to play in preventing suicide and promoting health, resilience, recovery, and wellness
for all.
Conducting assertive community outreach, including providing intensive support for people with
Providing regular training to frontline clinical staff on the management of suicide risk;
Managing patients with co-occurring disorders (mental and substance use disorder);
Conducting multidisciplinary reviews and sharing information with families after a suicide.
In 1998, few of the 91 mental health services in the study were carrying out any of these
recommendations. By 2004, about half were implementing at least seven recommendations, and by
2006, about 71 percent were doing so. Over time, as more recommendations were implemented, suicide
rates among patients declined. Each year, from 2004 to 2006, mental health services that implemented
seven or more recommendations had a lower suicide rate than those implementing six or fewer. Among all
recommendations, providing 24-hour crisis care was linked to the largest decrease in suicide rates.
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Strategic Direction 1:
The goals and objectives in this strategic direction seek to create supportive environments that will
promote the general health of the population and reduce the risk for suicidal behaviors and related
problems. As noted in the Introduction, suicide shares risk and protective factors with mental and
substance use disorders, trauma, and other types of violence, such as bullying and domestic violence.
As a result, a wide range of partners can contribute to suicide prevention, including organizations and
programs that promote the health of children, youth, families, working adults, older adults, and others in
the community. All of these partners should integrate suicide prevention into their work.
Eliminating the biases and prejudices associated with suicidal behaviors, mental and substance use
disorders, and exposure to violence is a key area of concern within this strategic direction. In particular,
there is a need to increase the understanding that mental and substance use disorders respond to specific
treatments and that recovery is possible.
Communication efforts, such as campaigns and social marketing interventions, can play an important
role in changing knowledge, attitudes, and behaviors to promote suicide prevention. Safe and positive
messages addressing mental illness, substance abuse, and suicide can help reduce prejudice and promote
help seeking. These types of messages can help create a supportive environment in which someone
who is experiencing problems feels comfortable seeking help, and where families and communities feel
empowered to link a person in crisis with sources of care and assist the person in attaining or regaining a
meaningful life.
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An example of a coordinated approach addressing multiple issues that share risk and protective factors
is the Good Behavior Game.51 This universal classroom behavior management method, used in first- and
second-grade classrooms, has been shown to contribute to the prevention of suicidal ideation, as well
as drug and alcohol use disorders, regular smoking, antisocial personality disorder, delinquency, and
incarceration for violent crimes. Several replications have provided similar results.
Objective 1.1: Integrate suicide prevention into the values, culture, leadership,
and work of a broad range of organizations and programs with a role to support
suicide prevention activities.
Suicide prevention should be integrated into the work of all organizations and programs that provide
services and support in the community. These organizations and programs include, but are not limited to:
Businesses, employers, and workplaces;
Faith-based programs;
Family, youth, and community service providers and organizations;
Funeral homes;
Hotlines, crisis lines, and call centers;
Organizations and programs that provide health care;
State and local aging services networks, and other programs that support older adults; and
Educational institutions, law enforcement, the justice system, and other institutions in
the community.
Health care providers, teachers, social workers, employers, members of the business community, and other
local resources can play an important role in suicide prevention. Strategies to involve these stakeholders
include obtaining support from members of school boards and other administrative structures, and
infusing suicide prevention into key professional meetings. Chambers of commerce and trade associations
can also be helpful partners in engaging the business community.
Integrating suicide prevention into the work of these community partners will promote greater
understanding of suicide and help counter the prejudice, silence, and denial that can prevent individuals
from seeking help. It also will support the delivery of suicide prevention activities that are culturally
competent, safe, and available to individuals who may lack access to health care.
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help improve services and outcomes, while promoting the greater sustainability of suicide prevention
efforts over the long term. The type of collaboration that will work best may vary by state/territory, tribe,
or community.
Clarifying each agency’s areas of focus and responsibility may be an important first step. This clarification
can make it easier for different agencies to work together and to obtain support for their respective suicide
prevention efforts. It also may be useful to identify a lead agency at the state and local levels that could help
bring together different partners with a role to play in suicide prevention. As an example, a recent report
from the Safe States Alliance identifies ways to organize and coordinate violence prevention efforts.52
The report presents the consensus of an expert panel regarding the roles that public health agencies at
the federal, state/territorial, tribal, and local levels could play in the prevention of violence, including
suicide prevention.
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fully. The development of partnerships with the private sector at the state/territorial, tribal, and local levels
would help strengthen and advance the implementation of suicide prevention plans.
Objective 1.5: Integrate suicide prevention into all relevant health care
reform efforts.
Changes in health care systems and policies provide important opportunities for integrating and
enhancing suicide prevention efforts. Health care reform efforts that increase access to care for mental and
substance use disorders can greatly contribute to suicide prevention. Examples include federal and state
parity laws requiring equal health insurance coverage for care for behavioral health (i.e., care for mental
and/or substance use disorders) as for physical health problems. Health care reform efforts can also be
used to create financial incentives for incorporating suicide prevention activities into clinical settings,
and to encourage the better coordination or integration of physical and behavioral health services. As an
example, the Prevention and Public Health Fund created by the Affordable Care Act provides support to
states and communities for integrating these services.
Efforts addressing changes to health care systems can provide opportunities to expand the use of practices
that are known to prevent suicide. For example, promoting the early identification of individuals with
high suicide risk and increasing the availability of effective treatments and followup care are important
strategies for improving health outcomes among these patients.
Integrating suicide prevention into health care reform is one of the four priority objectives identified by the
Action Alliance for 2012–14. The Action Alliance is working in partnership with the Centers for Medicare
& Medicaid Services (CMS) to ensure that suicide prevention is integrated into CMS policies and program
guidance to providers under Medicare and Medicaid. For example, as part of an incentive program
encouraging providers and hospitals nationwide to adopt electronic health records, CMS is considering the
adoption of quality measures specifically related to suicide.54 In addition, the Action Alliance is working
with other HHS Operating Divisions, such as the Health Resources and Services Administration, to
incorporate suicide prevention into health care reform.
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depending on the targeted segment of the population. For example, messages targeting policymakers
can promote the understanding that suicide is a preventable public health problem, and that mental and
physical health are equal and inseparable components of overall health. Family members and friends may
benefit from messages conveying the idea that mental and substance use disorders are real illnesses that
respond to specific treatments. Individuals in crisis may benefit from information regarding crisis lines
and other sources of assistance. These efforts should be conducted at multiple levels and align with other
suicide prevention interventions, such as training programs for health care providers or school-based
suicide prevention programs.
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An important first step to educating policymakers may be increasing their understanding of suicide,
its impact on their constituents and stakeholders, and effective solutions. These outcomes can motivate
leaders to take action by promoting suicide prevention initiatives, policies, and programs. Describing
effective programs of federal, state/territorial, tribal, and nonprofit agencies and local coalitions will help
build support for suicide prevention plans. It also may be useful to share evaluation data that show success
in reducing risk and increasing protective factors for suicide.
Suicide prevention can address sensitive topics such as the use of alcohol and other substances. There
is also growing consensus among researchers that prejudice and discrimination play a role in the higher
rates of mental disorders and suicide attempts among some populations.58 Placing the focus on promoting
public safety may help diffuse these types of tensions. Communications efforts should be framed in ways
that will speak to diverse policymakers at the national, state, tribal, and local levels, and build broad
support for suicide prevention.
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making choices based on audience.62 Another CDC publication provides guidance on how to write more
effectively using social media channels, such as Facebook, Twitter, and mobile phone text messaging.63
Suicide prevention programs that incorporate emerging technologies have a responsibility to ensure the
safety of users. They should consider in advance how to monitor these channels regularly and respond
to disclosures of suicidal thoughts or behaviors. These programs should include links to online crisis
resources, such as the Lifeline (800–273–TALK/8255). In addition, because many of these media include
user-generated content, it is important to think about how to ensure that messages are positive and
promote hope, connectedness, social support, resiliency, and help seeking.
Objective 2.4: Increase knowledge of the warning signs for suicide and of how
to connect individuals in crisis with assistance and care.
Family members, friends, teachers, coaches, coworkers, and others can play an important role in
recognizing when someone is in crisis and connecting the person with sources of help. However, many of
these persons may not know the warning signs of suicidal behavior or where a distressed person can go for
help (see warning signs in the Introduction). It is crucial to widely disseminate information on warning
signs, skills for interacting with individuals in crisis, and available resources (see Appendices D and E). In
doing so, it is important to use communication strategies that are research-based, thoughtfully planned,
and designed to meet the needs of specific groups. Incorporating stories of individuals who received help
and benefited may motivate others to take action.
In particular, there is a need to increase awareness of the role of crisis lines, such as the National Suicide
Prevention Lifeline/Veterans Crisis Line (800–273–TALK/8255) and other local crisis services, in
providing services and support to individuals in crisis. These service providers connect individuals in crisis
with local sources of quality support, risk assessment, and thoughtful intervention. A crisis line that offers
followup calls and services after an acute crisis can also help enhance safety and connect individuals with
appropriate care and services. New and emerging technologies, such as telehealth, chat and text services,
and online support groups, also show promise in allowing people to connect virtually to sources of care.
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It is also important to increase the understanding that mental and substance abuse disorders are treatable
and that recovery is possible. All in the community should understand the important role they can
play in promoting resilience and wellness and in promoting the full recovery of those who may be
experiencing problems.
Objective 3.1: Promote effective programs and practices that increase protection
from suicide risk.
Many factors can help prevent suicide by promoting physical, mental, emotional, and spiritual wellness. As
noted in the Introduction, these protective factors include problem-solving skills and social support that
can help individuals cope with emotional distress. The use of these tools should be the norm rather than
the exception. They should be taught at early ages to strengthen the ability of individuals and communities
to overcome challenges and crises.
Connectedness to others is another key protective factor that reduces suicide risk. Several programs that
have been shown to decrease suicidal thoughts or behaviors include connectedness components. For
example, a program for American Indian/Alaska Native (AI/AN) youth engaged natural helpers from the
community to identify and connect with at-risk youth.64 Connectedness was also the main component of
a post-crisis suicide prevention program for adults who presented in a hospital emergency department
(ED) for nonfatal, suicidal behaviors.65 Evidence from these and other programs suggest that promoting
connectedness is a viable strategy for preventing suicidal behaviors.
Policies and programs that foster social connectedness can help promote mental and physical health and
recovery. In particular, these programs and policies should focus on the groups that may be the most
isolated or marginalized. For example, social isolation can contribute to suicide and suicide attempts
among older adults, many of whom may have lost friends and family and/or have activity limitations that
make it difficult to stay connected with others. Family connectedness has been found to play an especially
strong protective role against suicidal behaviors among lesbian, gay, and bisexual youth.66
Many groups and organizations in the community, including schools, other youth-serving organizations,
faith-based organizations, and local aging services networks, can contribute to suicide prevention by
enhancing connectedness. These organizations can help ensure that social support is more widely available
from peers and others. Specific training addressing suicide prevention could enhance these providers’
ability to provide support to individuals at risk and make appropriate referrals.
Objective 3.2: Reduce the prejudice and discrimination associated with suicidal
behaviors and mental and substance use disorders.
Bias, prejudice, and discrimination discourage many people from seeking help, or even from sharing the
psychological distress that could lead to suicidal behaviors. In some cases, cultural or religious beliefs
that oppose suicide may help protect some individuals from suicidal behaviors. In others, they may
present barriers to help seeking and can increase the distress of those who have been bereaved by suicide.
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Strategies for addressing cultural or religious beliefs related to suicidal behaviors will be most effective
when they are grounded in a full understanding of and respect for the cultural context of these beliefs.
Broad communication, public education, and public policy efforts are needed to promote mental health,
increase understanding of mental and substance use disorders, and eliminate barriers to help seeking.
These efforts should increase awareness that no one is immune from experiencing these disorders. Seeking
treatment should be seen not as a sign of weakness, but as a step toward recovery.
Objective 3.3: Promote the understanding that recovery from mental and
substance use disorders is real and possible for all.
Social attitudes, bias, and discrimination often present barriers to treatment and undermine the recovery
of persons with mental or substance use disorders. Friends and family, health professionals, and others
may at times be overly protective or pessimistic about what someone with a mental or substance use
disorder will be able to achieve. These attitudes can undermine the person’s hope for the future and ability
to recover. A better understanding of crisis, trauma, and recovery can help individuals and groups in the
community promote resilience and wellness among all.
It is important to increase awareness that, in most cases, individuals who have a mental or substance use
disorder can recover and regain or attain meaningful lives. The disorder does not define the individual
and, in fact, the experience can provide an opportunity for reflection and change. Family members, peers,
mentors, individuals who have attempted suicide, individuals who have been bereaved by suicide, and
members of the faith community can be important sources of support. These individuals can help promote
hope and motivation for recovery; provide support for addressing specific stressors, such as the loss of a
job; and help foster a sense of meaning, purpose, and hope.
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substance abuse, and/or suicidal behaviors should promote hope, resiliency, and recovery. This approach
can motivate family, friends, and others to provide support and protection to individuals who may be at
risk for suicide and make it easier for a person in crisis to seek help and regain a meaningful life.
Objective 4.1: Encourage and recognize news organizations that develop and
implement policies and practices addressing the safe and responsible reporting
of suicide and other related behaviors.
Responsible, culturally competent coverage of suicide and other related behaviors can play an important
role in preventing suicide contagion. Shortly after the 2001 National Strategy was released, several public
and private groups came together to develop and promote a set of media recommendations entitled
Reporting on Suicide: Recommendations for the Media. These recommendations were disseminated to
the media through national, state, and tribal organizations. A followup workshop aimed at updating the
recommendations took place in August 2009. Recommendations for media reporting of suicide were
issued in April 2011 and are posted online (www.reportingonsuicide.org).68
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the online safety of users. These recommendations should be continuously reviewed and updated
to address new technologies, applications, and uses. As new media tools come into widespread use,
recommendations related to suicide prevention should be continuously reviewed and updated for use with
these technologies.
Objective 4.4: Develop and disseminate guidance for journalism and mass
communication schools regarding how to address consistent and safe messaging
on suicide and related behaviors in their curricula.
Schools of journalism, film, and other disciplines in the communications field play an important role
in training future journalists, writers, editors, photographers, directors, and other producers of media
content. The responsible depiction of suicidal behaviors and behavioral disorders should be addressed in
educational curricula of these schools and by the professions’ ethics governing bodies.
Because the sensational sells, many forces may push journalists to cover suicide in ways that are not
consistent with suicide prevention. Curriculum guidance should recognize this reality and make
the case for the responsible portrayal of suicide in ways that will resonate with journalists and other
content developers.
Participate in the National Action Alliance for Suicide Prevention, a public-private partnership
dedicated to advancing the National Strategy for Suicide Prevention. (Objective 1.4)
Ensure that promotion of the National Strategy for Suicide Prevention is included in the overall
Ensure that mental health services are included as a benefit in health plans and encourage
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Strategic Direction 2:
Suicide affects people of all ages in all parts of the country. The factors that contribute to these preventable
deaths are multiple and complex. Some of the factors that can increase the risk for suicidal behaviors
may be longstanding, such as having a substance use disorder. Others, such as the loss of a loved one or
career failure, may be recent events that could increase the immediate risk for suicidal behaviors. Suicide
prevention requires that support systems, services, and resources be in place to promote wellness and help
individuals successfully navigate these challenges.
Clinical and community-based programs and services play a key role in promoting wellness, building
resilience, and preventing suicidal behaviors among various groups. Clinical preventive services, including
suicide assessment and preventive screening by primary care and other health care providers, are crucial to
assessing suicide risk and connecting individuals at risk for suicide to available clinical services and other
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sources of care. Screening for depression and alcohol misuse have been endorsed by the United States
Preventive Services Task Force and are now covered as preventive services under Medicare.
A wide range of community partners, including schools, workplaces, and faith-based organizations,
also have an important role to play in delivering prevention programs and services to diverse groups
at the local level. These community-based professionals and organizations should be competent in
serving various groups, including racial, ethnic, sexual, and gender minorities, in a way that is culturally
and linguistically appropriate. Greater coordination among community and clinical preventive service
providers can have synergistic effects in preventing suicide and related behaviors.
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community level participants. In addition, these efforts should be evaluated and modified accordingly to
assure effectiveness.
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Several groups that have a higher risk for suicidal behavior are listed in Appendix D, which includes
information on specific risk and protective factors, evidence-based interventions and best practices for
suicide prevention, and resources.
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or suffocation. Installing bridge barriers or otherwise restricting access to popular jump sites may also
prevent deaths, depending on specific local conditions.
Although this goal focuses on reducing access to lethal means among individuals at risk, evidence for
means restriction has come from situations in which a universal approach was applied to the entire
population. For example, the detoxification of domestic gas in the United Kingdom and discontinuation
of highly toxic pesticides in Sri Lanka were universal measures associated with 30 percent and 50 percent
reductions in suicide, respectively.81, 82
Objective 6.1: Encourage providers who interact with individuals at risk for
suicide to routinely assess for access to lethal means.
Professionals who provide health care and other services to patients or clients at risk for suicide and their
families and other caregivers are in a unique position to ask about the presence of lethal means and work
with these individuals and their support networks to reduce access. These professionals may include health
care providers, social service workers, clergy, first responders, school personnel, professionals working in
the criminal justice system, and others who may interact with individuals in crisis. These providers can
educate individuals with suicide risk and their loved ones about safe firearm storage and access, as well
as the appropriate storage of alcoholic beverages, prescription drugs, over-the-counter medications, and
poisons that may be available in the household. However, many may fail to do so, or do so only when a
patient is identified as being at a very high risk for suicide.
There are steps that can be taken to prevent accidents as well as suicides. Providers should also
educate patients and care providers about reducing the stock of medicine in the medicine cabinet to a
nonlethal quantity, and locking medicines that are commonly abused (e.g., prescription painkillers and
benzodiazepines, which are medications used to induce sleep, relieve anxiety and muscle spasms, and
prevent seizures). This approach can be useful in helping to prevent suicide, as well as unintentional
overdoses and substance abuse.
Objective 6.2: Partner with firearm dealers and gun owner groups to incorporate
suicide awareness as a basic tenet of firearm safety and responsible firearm
ownership.
Among persons who attempt suicide, those who use firearms are more likely to die than those who use
other means. Reaching out to gun owners, firearm dealers, shooting clubs, hunting organizations, and
others to promote firearm safety and increase their involvement in suicide prevention is an important
strategy for reducing suicide risk.
Most firearm safety educational materials focus on the prevention of accidents rather than suicide.
Brochures and websites promoting firearm safety to gun owners could include a statement regarding the
importance of being alert to signs of suicide in a loved one and keeping firearms out of the person’s reach.
For example, all firearms in the household could be temporarily stored with a friend or relative or in
storage facility. At a minimum, all guns should be securely locked away from the vulnerable person’s access
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until he or she has recovered. Partnering with gun-owner groups to craft and deliver this message will help
ensure that it is culturally relevant, technically accurate, comes from a trusted source, and does not have an
anti-gun bias.
Most gun-owner groups promote the safe storage of firearms when not in use (i.e., stored locked and
unloaded, with ammunition locked separately) to protect against accidents, theft, and unauthorized use.
The safe storage of firearms among the general population can help prevent suicide, particularly from
attempts that take place during short-lived crises and attempts made by individuals living in a household
where firearms are present. Gun-owner groups are in an excellent position to promote this message.
Objective 6.3: Develop and implement new safety technologies to reduce access
to lethal means.
Many safety technologies can help prevent suicide by reducing access to lethal means of self-injury. New
technologies can also be used to prevent suicide by poisoning by reducing the carbon monoxide content
of motor vehicle exhaust, restricting pack sizes to prevent overdoses of more toxic medications, and
encouraging the use of electronic pill dispensing lockboxes for people who rely on medication but are
at risk of overdosing. Options for preventing suicide from jumps include incorporating architecturally
unobtrusive barriers into the original design of high bridges and/or retrofitting bridges that are currently
popular jump sites. These types of approaches should be used more widely. There is also a need to research,
develop, and implement other technologies that will prevent suicide by reducing access to lethal means.
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Objective 7.2: Provide training to mental health and substance abuse providers
on the recognition, assessment, and management of at-risk behavior, and the
delivery of effective clinical care for people with suicide risk.
Mental health and substance abuse providers should have the essential foundation of attitudes, knowledge,
and clinical prevention skills to address and reduce suicide risk and increase protective factors among
patients. Caring for individuals with suicide risk requires being able to work collaboratively with the
patient. Skill development, practice using those skills, and a culture of shared responsibility can help build
comfort, confidence, and competency to engage and care for these individuals.
Training programs for mental health and substance abuse providers should seek to:
Increase feelings of confidence and empowerment in working with patients with suicide risk;
Address the emotional and legal issues associated with adverse patient outcomes, including death
by suicide;
Equip practitioners with attitudes, knowledge, and skills to cope with sentinel events (unanticipated
events resulting in death or serious physical or psychological injury), along with effective clinical
preventive procedures to minimize risk of litigation;
Educate practitioners about how to exchange confidential patient information appropriately to
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suicide risk, including addressing the value of shared responsibility and collaborative care, and
increasing knowledge and skills for communicating collaboratively with patients, families, significant
Address the provision of effective support services for those who have been bereaved by suicide.
These training objectives should guide the development of the core education and training guidelines
discussed under Objective 7.3.
Objective 7.3: Develop and promote the adoption of core education and training
guidelines on the prevention of suicide and related behaviors by all health
professions, including graduate and continuing education.
All education and training programs for health professionals, including graduate and continuing education
programs for these professions, should adopt core education and training guidelines addressing the
prevention of suicide and related behaviors. All degree-granting undergraduate and graduate programs
in relevant professions should include these guidelines as a part of their curricula. Programs should also
ensure that graduates achieve the relevant core competencies in suicide prevention appropriate for their
respective discipline. For example, guidelines for the graduate and continuing education of clinicians
should address the safer dispensing of medications for individuals at high risk for suicide. A useful
resource for primary care providers is the review article Practical Suicide-Risk Management for the Busy
Primary Care Physician, which provides a summary of how to identify patients at risk for suicide, assess
them, and manage suicide risk.84
Objective 7.4: Promote the adoption of core education and training guidelines
on the prevention of suicide and related behaviors by credentialing and
accreditation bodies.
The inclusion of core education training in recertification or licensing programs can help ensure that
professionals who have completed training acquire competence in addressing suicidal behaviors and
remain competent over time. In most states and territories, physicians, psychologists, social workers,
nurses, and other health professionals must complete licensing examinations or recertification programs
in order to maintain active licenses and/or professional certifications. Accrediting and credentialing
organizations should promote evidence-based and best practice suicide prevention training for the
organizations and practitioners they accredit or credential. In addition, because suicide shares risk and
protective factors with mental and substance use disorders, as well as with trauma and interpersonal
violence, suicide-related curricula should be linked with training on these related topics. Accreditation
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standards should be encouraged to require that professionals be trained and tested on that content via
certification and licensing exams.
Many groups, including state governments, can help support the incorporation of suicide prevention into
the training of professionals in various disciplines. As an example, the State of Washington has passed
a law requiring that a broad array of health professionals (e.g., mental health counselors, psychologists,
family therapists) complete a training program in suicide prevention at least once every 6 years. Known as
the Matt Adler Suicide Assessment, Treatment, and Management Training Act of 2012, the law comes into
effect in January 2014.
Objective 7.5: Develop and implement protocols and programs for clinicians
and clinical supervisors, first responders, crisis staff, and others on how to
implement effective strategies for communicating and collaboratively managing
suicide risk.
Communication and collaboration across multiple levels of care is a key to the successful management
of suicide risk. Clinical preventive and communication protocols for clinicians and clinical supervisors,
emergency workers, crisis staff, professionals who provide adult and child protective services, and others
providing support to individuals with suicide risk can help improve communication and collaborative
management of suicide risk. Care for individuals with suicide risk must be comprehensive and continuous
until the risk is reduced. Each setting and service provider has an important role in verifying that the
subsequent supportive services have the information and resources they need in order to help keep the
individual safe.
Protocols and programs for clinicians and clinical supervisors, first responders, crisis staff, and
others should address the implementation of effective strategies for improving communication and
collaboratively managing suicide risk. In particular, there is a need to promote the sharing of information
among different providers and the use of team-based care for managing suicide risk.
A promising example of a collaborative care approach to suicide prevention is the Prevention of Suicide in
Primary Care Elderly: Collaborative Trial (PROSPECT). Conducted in 20 primary care practices in urban,
suburban, and rural areas, the study found that collaborative care was more effective than treatment as
usual in reducing suicide risk in patients aged 60 years or older.85 Care managers, including social workers,
nurses, and psychologists, implemented the intervention, which helped physicians to recognize depression,
offered recommendations, monitored depressive symptoms and side effects, offered interpersonal
psychotherapy (IPT) to patients who refused medication, and provided followup, including making house
calls to patients unable to travel. At the end of this 2-year trial, suicidal ideation was 2.2 times less likely in
the collaborative care group than in the comparison group.
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Educate clergy, parent groups, schools, juvenile justice personnel, rehabilitation centers, defense
and divorce attorneys, and others about the importance of promoting efforts to reduce access to
lethal means among individuals at risk for suicide. (Goal 6)
Individuals and Families Can:
Learn the signs and symptoms of suicide and suicidal behaviors and how to reach out to those who
may be at risk. (Objective 5.3)
Store household firearms locked and unloaded with ammunition locked separately and take
additional measures if a household member is at high risk for suicide. (Objective 6.1)
Dispose of unwanted medications, particularly those that are toxic or abuse-prone, and take
additional measures (e.g., a medication lock box) if a member of the household is at high risk for
suicide. (Objective 6.1)
Strategic Direction 3:
Treatment and Support Services
Individuals at high risk for suicide require clinical evaluation and care to identify and treat mental
health and medical conditions, and to specifically address suicide risk. In the past, it was believed that
appropriately treating underlying conditions (e.g., mood disorders, substance abuse) would remove the
risk for suicide. However, this is not always the case. A growing body of evidence suggests that suicide
prevention is enhanced when specific treatments for underlying conditions are combined with strategies
that directly address suicide risk.
Evidence-based and promising approaches for caring for high-risk patients include safety planning
(i.e., working collaboratively with each patient to develop an action plan for times of crises) and specific
forms of psychotherapy that can be used to support treatment for underlying mental health conditions.
Addressing suicide risk may be particularly important when treating individuals who have survived a
suicide attempt. There is now substantial evidence that interventions such as dialectical behavior therapy
(DBT) and cognitive behavior therapy for suicide prevention (CBT-SP) can help reduce suicidal behaviors
among these patients. In addition, clozapine has been found to be effective in reducing suicidal behaviors
among patients with schizophrenia86 and lithium shows promise in patients with mood disorders.87
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Principles that should guide care for individuals with high suicide risk include the following:
Provision of evidence-based treatment as soon as possible after suicide risk is identified;
Person- and relationship-centered care, which includes improving patient-provider communication,
involving individuals with suicide risk in the development of safety plans, and providing care that is
Culturally competent care that addresses the needs of diverse groups of patients, including linguistic,
Multiple points of access to appropriate treatment and a focus on providing support in the least
restrictive environment;
Integration of care across various systems and settings (via several possible models, from
communication and collaboration to full integration) and shared reporting of client outcomes;
Continuity of care for individuals with suicide risk with a particular focus on immediate (if possible,
within 48 hours) and continuous followup after a suicide attempt following discharge from a hospital,
ED, or other inpatient facility;
Appropriate empowerment of families and significant others in treatment, peer support, and
post-discharge followup;
Use of systems-level strategies, such as establishing the organizational goal of eliminating deaths by
suicide, tracking and investigating suicide deaths, and using other continuous quality improvement
efforts; and
Recovery-oriented services that are based on the following understanding: recovery emerges from
hope, is person-driven, occurs through many pathways, is holistic, is supported by peers and allies,
is supported through relationships and social networks, is culturally based, is grounded in respect, is
supported by addressing trauma, and involves the individual, family, and community.88
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crisis care was associated with the greatest reduction in suicide rates. Other recommendations included:
assertive, proactive outreach; followup within 7 days of inpatient discharge; training of clinical staff in the
management of suicide risk every 3 years; a dual diagnosis policy for those with both mental disorders and
substance abuse; and multidisciplinary review and information sharing with families following a suicide.
VA and its health system, the Veteran’s Health Administration (VHA), also have adopted a comprehensive
approach in which suicide prevention is a core component of mental health and substance abuse services.
As part of this approach, a suicide prevention coordinator is placed at every VA medical center in the
country. Preliminary data suggest that the implementation of these programs has been associated with
a reduction in suicide among important high-risk subgroups of those receiving health care through the
VHA, including men in midlife.90, 91
Other programs that have garnered attention for their comprehensive approaches and that report
promising preliminary data include the Henry Ford Health System’s (HFHS) “Perfect Depression Care”49
and the Central Arizona Programmatic Suicide Deterrent Project.89 Although more research is needed,
initial findings suggest that progress can be made when health systems or other organizations focus on
making suicide prevention a core priority by obtaining leadership support, changing the organizational
culture around suicide prevention, and engaging each component of a system to assume its legitimate role
in suicide prevention.
While providers of mental health and substance abuse services have a special responsibility for addressing
suicide risk, suicide prevention should not be viewed as an area of specialization that applies only to
these professionals or to a single setting, such as inpatient psychiatry. Suicide prevention requires the
active engagement of health and social services, as well as the coordination of care across multiple
settings, thereby ensuring continuity of care and promoting patient safety. Services addressing mental and
substance use disorders, as well as suicide prevention, can be provided in numerous settings, including
crisis centers, health centers, clinics, other locations serving particular groups (e.g., older adults), and in
the home (e.g., visiting nurse services, home psychotherapy, or hospice care).
There is substantial evidence that discontinuities in treatment and fragmentation of care can increase the
risk for suicide. Death by suicide in the period after discharge from inpatient psychiatric units is more
frequent than at any other time during treatment.92 Similarly, the time following ED discharge also is
a period of high risk for suicide.93 There is also reason for substantial concern in the period following
discharge from residential addiction treatment.94 Proactive followup and active engagement strategies
following discharge have been found to help reduce death by suicide and suicide attempts.65, 95
Increasing collaboration among providers is also a promising, viable, and efficient way to increase access to
suicide prevention and treatment services. This approach can help minimize prejudice and discrimination,
while increasing opportunities to improve overall health outcomes. Even in cases when full integration
may not be feasible, increased coordination of services and continuity of care can greatly improve care and
lead to better patient outcomes.
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Objective 8.2: Develop and implement protocols for delivering services for
individuals with suicide risk in the most collaborative, responsive, and least
restrictive settings.
Trusting therapeutic relationships are fundamental to reducing suicide risk and promoting recovery and
wellness. These relationships are most productive when the patient is actively engaged in making choices
that will keep him or her safe. There is a need to promote culturally appropriate strategies that will foster
therapeutic alliances between patients and providers. The personal needs, wishes, and resources of the
patient should be the foundation for developing a plan for continuing care and safety. This plan should be
developed through direct and open communication and should engage and empower the patient. Where
appropriate and practical, families and significant others should be engaged and empowered as well.
Psychiatric hospitalization, voluntary or involuntary, may be an effective mechanism for preventing suicide
over the short term. However, the decision to hospitalize could be a barrier to the development of a long-
term therapeutic alliance between the patient and his or her mental health providers. Short-term gains in
safety may be neutralized or even outweighed by longer-term increases in risk if patients are reluctant to
disclose suicidal thoughts because they perceive a lack of acceptance or sensitivity to cultural values, or if
they are afraid of losing their autonomy or being forced into treatment. One way to address this trade-off
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is to ensure that inpatient psychiatric units are recovery-oriented and prepared to ensure continuity of care
at the point of discharge. Another strategy is to develop alternatives to hospitalization for persons who are
not at imminent risk.
There is also a need to identify alternatives to coercion, restraint, and involuntary treatment as ways to
ensure the safety of patients in crisis. Because past trauma or abuse increases the risk for suicide, confining
people against their will can retraumatize patients. It may also make these patients reluctant to seek help in
the future for fear of being discriminated against, traumatized, or imprisoned. There is a need to develop
and implement protocols for delivering services in the least restrictive settings consistent with safety.
Protocols should be developed and implemented for delivering services to persons with high suicide risk
that promote collaboration and responsiveness. At a minimum, these protocols would instill attitudes and
beliefs on the value of shared responsibility and collaborative care and promote effective communication
with patients, families, and significant others.
Objective 8.4: Promote continuity of care and the safety and well-being of all
patients treated for suicide risk in emergency departments or hospital inpatient
units.
Patients leaving the ED or hospital inpatient unit after a suicide attempt, or otherwise at a high risk for
suicide, require rapid, proactive followup. Having survived a suicide attempt is one of the most significant
risk factors for later death by suicide. The risk is particularly high in the weeks and months following the
attempt, including the period after discharge from acute care settings such as EDs and inpatient psychiatric
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units.97, 98 Among patients with high suicide risk, particularly those who have attempted suicide, immediate
followup and continuity of care are crucial to promoting positive outcomes.43
When patients with high suicide risk come to an ED, they may receive limited mental health services,99
may not receive adequate treatment for underlying mental health or substance use disorders, and
frequently do not receive any followup care.100, 101 All patients who present to the ED for a suicide attempt
or who are at risk for suicide require mental health evaluations. Should they not require acute inpatient
care, they should be informed about risks during the discharge period and be referred for mental health
services before discharge from the ED. However, although referral is necessary, it may not be sufficient.
There is increasing evidence that specific outreach programs can be highly effective in increasing the
proportion of patients who engage in mental health care after hospitalization.102
For patients who are transferred from the ED to medical-surgical services for the treatment of injuries
related to a suicide attempt, followup mental health evaluations should be conducted before discharge to
decide between transfer to a mental health inpatient unit or referral to outpatient care. These evaluations
should consider the support available from family and friends and the patient’s clinical status. Before a
decision to discharge is made, followup appointments for mental health care should be made and patients
(and families or friends) should be coached about the importance of continuity in care.
All patients who are admitted to an inpatient mental health unit require followup mental health services
after discharge, as well as connections to community-based supports. Health care systems should seek
to dramatically shorten the time between inpatient discharge and followup outpatient treatment. For
example, EDs and others providing services to these patients could set a goal of ensuring that followup
occurs within 48 hours or, at most, within a week of discharge.
Continuity of care following a suicide attempt should represent a collaborative approach between patient
and provider that gives the patient a feeling of connectedness. Strategies may include telephone reminders
of appointments, providing a “crisis card” with emergency phone numbers and safety measures, and/or
sending a letter of support.103 Many types of motivational counseling and case management can also be
used to promote adherence to the recommended treatment.
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holds promise for increasing the quality of care, and should not focus on attributing blame to providers or
to individuals in crisis.
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health distress by serving as a liaison with the various agencies within the federal and state governments,
thereby ensuring access to benefits and services that address these issues and contribute to a positive
transition to civilian life.
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Suicide risk assessment programs often target patients with known risk factors for suicide, including
those who have previously expressed suicidal thoughts or made a suicide attempt and persons with
mood or substance use disorders. Treatment of patients with suicide risk often includes medication
(e.g., antidepressants) and psychosocial approaches such as cognitive-behavioral therapy and supportive
counseling. Because suicide attempts are known to be a strong predictor of future attempts and deaths by
suicide, continuity of care is critical for these patients. Effective clinical care should include monitoring
patients for a suicide attempt after an ED visit or hospitalization and providing outreach, mental health
followup, therapy, and case management.
Objective 9.1: Adopt, disseminate, and implement guidelines for the assessment
of suicide risk among persons receiving care in all settings.
The assessment of suicide risk is critical to identifying high-risk individuals and providing needed
services and supports. Assessment of suicide risk should be an integral part of primary care, hospital care
(particularly ED care), care for mental and substance use disorders, crisis response (e.g., help lines, mobile
teams, first responders, crisis chat services), and of the care provided in skilled nursing facilities. Any
person identified as being at a possible risk for suicide should be formally assessed for suicidal thoughts,
plans, intent, access to lethal means, a history of previous attempts, the presence of acute risk factors
(including problems in the family and other social relationships, work or school, finances, and the legal
system), and level of risk. Persons identified as being at risk for suicide should have immediate access to
needed clinical care and support.
Tools and methods to help detect risk, conduct assessments, intervene for safety, and deliver quality
treatment and support are available but not widely used. Research has not yet identified a simple, easily
administered scale leading to a score that can provide a quantifiable substitute for clinical decision-
making and judgment. However, reliable and valid instruments do exist and can be a useful component
of a full evaluation. Guidelines for risk assessment, along with appropriate tools and protocols, must be
disseminated among all settings that provide care for individuals with suicide risk.
Strategies for assessing suicide risk should be tailored to the individual and context. For individuals
in primary care without known risk factors, a staged approach may be useful, where evaluations for
suicide risk are conducted when patients have a positive screen or show evidence of a mental health or
substance use disorder or a chronic pain syndrome. In these cases, evaluations for the risk of suicide
should be conducted at the initial diagnostic and treatment planning evaluation and when there are
significant changes in symptoms and treatments. For individuals who have previously been at high risk,
evaluations should be conducted on a frequent, regularly scheduled basis, when there are significant
changes in symptoms or treatments, and when a person experiences stressful events. Guidelines for suicide
risk assessment should be meaningfully related to the training objectives listed in Objective 7.2 of this
National Strategy.
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Safety planning;
Alignment of clinical approaches with needs (e.g., underlying psychiatric and/or substance use
Objective 9.3: Promote the safe disclosure of suicidal thoughts and behaviors by
all patients.
Settings that provide care to patients with suicide risk must be nonjudgmental and psychologically safe
places in which to receive services. Patients who have thoughts of suicide may feel embarrassed, guilty, and
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fearful of disclosing their thoughts and feelings to others. These patients may also fear losing autonomy or
the ability to make their own treatment decisions. To address these barriers to treatment, collaborative and
non-coercive approaches should be used whenever possible. Health care providers and other caregivers
must have the skills required to promote disclosure. Individuals contacting a potential helper must feel
comfortable to disclose their desire or intent to die and their thoughts of suicide. They must feel confident
that the potential caregiver will be accepting and in a position to offer nonjudgmental help.
Anxiety about asking suicide-related questions may also be a barrier to identifying individuals at risk.
Education, training, and rehearsal of ways to address the disclosure of suicide risk can help ease these
concerns. System-based approaches that give providers access to resources that can help them manage
someone who is suicidal also can help reduce provider anxiety regarding the disclosure of suicide-related
thoughts and behaviors. For example, VA places a suicide prevention coordinator at each medical center,
as a resource for providers who need to make difficult clinical judgments.
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Objective 9.5: Adopt and implement policies and procedures to assess suicide
risk and intervene to promote safety and reduce suicidal behaviors among
patients receiving care for mental and/or substance use disorders.
Strategies for monitoring patients and identifying those at risk in a number of contexts are also needed.
Monitoring should be more frequent and more focused for those people known to have risk factors such
as mental or substance use disorders, chronic pain, or disability. Monitoring should be more intensive for
those identified as being at high risk for suicidal behaviors. Clinical care for individuals at a high risk for
suicide, including those who have survived a suicide attempt, should recognize and support recovery and
should also be based on the understanding that individuals remain at risk for extended periods of time.
Regularly scheduled monitoring should focus on evaluating changes in symptoms of medical and mental
health conditions, changes in protective factors such as social networks, the occurrence and impact of
stressful events, and the recurrence of suicidal ideation, plans, or intent.
Specialty centers that provide care for mental and substance use disorders should have in place policies,
procedures, and programs designed to identify the level of suicide risk and intervene to prevent suicide
among their patients. Evaluation of these policies and procedures over time can contribute to the more
effective and efficient delivery of health care to patients with high suicide risk.
Although assessment and intervention are different processes, policies and procedures in these two areas
must be coordinated. Put simply, a lack of knowledge and resources to respond to patients found to be
at high risk for suicide could represent a barrier to case identification. Policies and procedures should
recognize that managing a patient at a high risk for suicide can take more time than a standard encounter
and may require the involvement of more than one provider.
As noted earlier, interventions for patients at risk for suicide should combine care for underlying
conditions with strategies that directly address suicide risk. At the same time, it is important to reevaluate
treatments for mental health and substance use disorders to ensure that they are appropriate, and that they
address both the management of symptoms and recovery. For those with a serious mental illness, ensuring
that the treatment plan is recovery oriented can be lifesaving.
Collaborative safety planning has been found to be a component of effective treatment of suicidal risk.
Health systems such as VA have begun to require safety planning as an intervention within their systems
for patients at high risk.
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suicidal with active psychosis). These protocols should emphasize patient-centered and stepped
approaches that allow relative suicide risk to be assessed and matched with a continuum of services. For
example, individuals who are identified as being at a high risk for suicide may require intensive outpatient
suicide-specific mental health treatment. Those who are intoxicated and suicidal will, in general, have to
be evaluated after they have become sober before they can be discharged. Seriously ill patients with high
suicide risk may require partial hospitalization or short-term psychiatric inpatient stays.
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bereaved by suicide often have difficulty finding the services they need when they are ready to access them.
Developing comprehensive national guidelines for effective support will provide a “roadmap” for the kinds
of services that communities can work to provide for these groups. This support can include, but is not
limited to, outreach teams of professionals and trained individuals who have been bereaved by suicide,
face-to-face and online support groups, memorial services, and other opportunities for those who have
been bereaved by suicide to interact with each other and find positive and culturally appropriate ways to
deal with their grief.
The Action Alliance’s Task Force on Survivors of Suicide Loss is working toward the development of
consensus guidelines for the creation and implementation of effective, comprehensive support programs
for individuals affected by a suicide loss. The Task Force will review existing evidence regarding model
services and programs, draft consensus guidelines incorporating input from various groups, and submit
the guidelines for inclusion in the Best Practices Registry for Suicide Prevention.
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at risk for suicide. Guidelines and protocols are needed to support the development of such services for
those who have attempted suicide, as well as technical assistance to assist with the dissemination and
implementation of these tools.
Objective 10.5: Provide health care providers, first responders, and others with
care and support when a patient under their care dies by suicide.
Clinicians, first responders, emergency personnel, and other medical professionals who lose a patient to
suicide should be provided with support to deal with the emotional aftermath of this traumatic event.
Such support should address trauma and grief reactions and potential suicide risk among caregivers.
Mechanisms for review of such deaths should avoid blaming the caregiver. Instead, the goal should be to
respond to the caregiver’s need for support and help the provider respond to patients who may be at risk
for suicide in the future.
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(Objective 10.4)
crisis teams, and social services to ensure timely access to care for individuals with suicide risk.
(Objective 8.3)
individuals at suicide risk during treatment and/or after discharge from an ED or inpatient unit.
(Objective 9.4)
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Strategic Direction 4:
The National Strategy’s fourth strategic direction addresses suicide prevention surveillance, research, and
evaluation activities, which are closely linked to the goals and objectives in the other three areas. Public
health surveillance refers to the ongoing, systematic collection, analysis, interpretation, and timely use of
data for public health action to reduce morbidity and mortality. In contrast, research and evaluation are
activities that assess the effectiveness of particular interventions, thereby adding to the knowledge base in
the area of suicide prevention.
The past decade has seen substantial improvements in suicide-related surveillance, research, and
evaluation. However, additional efforts are needed to inform and guide suicide prevention efforts
nationwide. The collection and integration of surveillance data should be expanded and improved. In
addition, although some evidence is available regarding the effectiveness of particular interventions and
approaches, there is a need to assess the effectiveness of new and promising practices.
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Examples of existing nationally representative data sources containing information regarding suicidal
behaviors include:
CDC’s National Vital Statistics System: annual data on all suicide deaths occurring in the U.S.;
CDC’s NVDRS: annual data on suicide deaths from 18 states; available from
WISQARS (www.cdc.gov/injury/wisqars/nvdrs.html);
CDC’s Youth Risk Behavior Surveillance System: data released every 2 years on suicide ideation and
SAMHSA’s National Survey on Drug Use and Health: annual survey that, since 2008, has included
It is important to strengthen systems and to improve the quality of the data collected for surveillance
purposes. It is equally necessary to enhance the ability of jurisdictions to use available information for
strategic planning aimed at preventing suicidal behaviors.
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Data on fatal and nonfatal self-directed violence often are not standardized. To address this issue, in 2011,
CDC published the report Self-Directed Violence Surveillance: Uniform Definitions and Recommended Data
Elements.108 The definitions and data elements were developed in collaboration with the VA and have been
adopted by the Department of Defense.
Lack of external cause-of-injury coding in administrative datasets (e.g., ED, hospital discharge) greatly
reduces the utility of these datasets. The CDC has developed an action agenda for improving external cause
coding that could be a useful framework for addressing this issue within these administrative datasets.109
Efforts to link and analyze information coming from separate data systems, such as law enforcement,
emergency medical services, and hospitals, are also needed. Such linked data can provide much more
comprehensive information about an event, its circumstances, the occurrence and severity of injury, the
type and cost of treatment received, and the outcome in terms of both morbidity and mortality.
Objective 11.3: Improve and expand state/territorial, tribal, and local public
health capacity to routinely collect, analyze, report, and use suicide-related data
to implement prevention efforts and inform policy decisions.
The surveillance of suicidal behaviors and related issues (e.g., mental and substance use disorders) has
improved over the years, but additional advances are needed. In particular, there is a need to increase
the number of states and territories that are funded to integrate data sets as a part of NVDRS and to
improve relevant data sets and facilitate access to them. In addition, staff members in states/territories,
tribes, and local governments require training on how to analyze and interpret data for policy and
prevention purposes.
Although national data provide an overall view of the problem, local data are key to effective prevention
efforts. State/territorial, tribal, and local suicide rates vary considerably from national rates. There is a need
to promote the development of local reports on suicide and suicide attempts, and to integrate data from
multiple data management systems. These reports should describe the magnitude of the suicide problem
and how suicide differentially affects particular groups. In addition, the reports should also address the
use of mental health and substance use services. These publications would be useful in tracking trends in
suicide rates over time, identifying changes in groups at risk and methods used, and evaluating suicide
prevention efforts. At the local level, they could serve as a resource for developing timely and targeted
interventions to prevent suicidal behaviors. State epidemiologists and suicide prevention coordinators
could play an important role in supporting and providing assistance for these local efforts.
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factors. Questions about suicide attempts should identify the person’s age at the time of the attempt and
whether medical attention was required. Data collection tools also should include questions that better
identify vulnerable populations, such as items addressing sexual orientation and gender identity.
Exposure to suicide, particularly of someone emotionally close to the bereaved, can increase the risk for
depression, complicated grief and trauma reactions, and suicide. Yet little is known about the number
of people who have been exposed to suicide and about those who have been adversely affected by that
exposure. Nationally representative surveys and other data collection instruments and systems should
include questions on exposure to suicide and its links with suicidal thoughts and behaviors, mental and
substance use disorders, and violence. Obtaining this data would help greatly in planning support services
for those who have been bereaved by suicide.
There also is a need to collect suicide data on deaths among those who are currently receiving active
inpatient or outpatient care (e.g., outpatient mental health care, inpatient cancer treatment). Although
these events may be particularly amenable to prevention, there is currently no national system that can
provide this information.
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attempts, may serve as a sufficiently powerful proxy (i.e., substitute) measure to address some specific
research questions.
A national repository of research methods would be a useful resource for suicide prevention researchers.
The repository could include a link to national databases (e.g., CDC, national, state/territorial, tribal,
and local) that can be used as research tools. Other contents could include information on appropriate
and rigorous study designs, common measures that should be used in research studies, successful
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Objective 13.4: Evaluate the impact and effectiveness of the National Strategy
for Suicide Prevention in reducing suicide morbidity and mortality.
The National Strategy represents a comprehensive, long-term approach to suicide prevention. As discussed
in the Introduction section (under “Looking Ahead”), the goals and objectives are broad in scope and
encompass a wide range of activities.
The National Strategy represents a roadmap that, when followed, will lead to the vision of a nation
free from the tragic experience of suicide. Different groups (e.g., associations, government agencies,
educational institutions, health systems) may find it useful to review the goals and objectives in the
National Strategy and identify their own priority areas for action.
As an example, the Action Alliance has identified four priority areas for 2012–14 and will monitor
progress toward their achievement. Several considerations helped guide the development of this action
agenda, including the potential impact on suicide-related morbidity and mortality and the availability of
organizations, agencies, or other groups that may be willing to take on different roles in implementing
activities and evaluating progress.
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Improve data linkage across agencies and organizations, including hospitals, psychiatric and other
medical institutions, and police departments, to better capture information on suicide attempts.
(Objective 11.2)
Businesses and Employers Can:
Evaluate the effectiveness of workplace wellness programs in reducing suicide risk. (Objective 13.1)
Health Care Systems, Insurers, and Clinicians Can:
Implement the recommendations for health care providers in CDC’s action plan for improving
external cause of injury coding within administrative data, such as emergency department and
hospital discharge systems. (Objective 11.2)
Routinely document suicide-related information (e.g., alcohol use, drug use, description of intent) in
emergency department charts. (Objective 11.2)
Initiate continuous quality improvement studies to determine the effectiveness of policies and
procedures intended to rapidly connect individuals at risk for suicide with services. (Objective 13.1)
Schools, Colleges, and Universities Can:
Conduct research to identify new, effective policy and program interventions to reduce suicide and
suicidal behavior. (Objective 12.1)
Share suicide-related research findings with state and local suicide prevention coalitions, health care
providers, and other relevant practitioners. (Objective 12.3)
Nonprofit, Community-, and Faith-Based Organizations Can:
Work with a local university to evaluate your suicide prevention program. (Objective 13.1)
Individuals and Families Can:
Participate in surveys and other data collection efforts addressing suicide and related behaviors.
(Objective 11.4)
Support evaluation of suicide prevention programs. (Objective 13.1)
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Objective 1.5: Integrate suicide prevention into all relevant health care reform efforts.
Objective 2.3: Increase communication efforts conducted online that promote positive
messages and support safe crisis intervention strategies.
Objective 2.4: Increase knowledge of the warning signs for suicide and of how to
connect individuals in crisis with assistance and care.
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GOAL 3. Increase knowledge of the factors that offer protection from suicidal
behaviors and that promote wellness and recovery.
Objective 3.1: Promote effective programs and practices that increase protection from
suicide risk.
Objective 3.2: Reduce the prejudice and discrimination associated with suicidal
behaviors and mental and substance use disorders.
Objective 3.3: Promote the understanding that recovery from mental and substance
use disorders is possible for all.
Objective 4.2: Encourage and recognize members of the entertainment industry who
follow recommendations regarding the accurate and responsible portrayals of suicide
and other related behaviors.
Objective 4.3: Develop, implement, monitor, and update guidelines on the safety of
online content for new and emerging communication technologies and applications.
Objective 4.4: Develop and disseminate guidance for journalism and mass
communication schools regarding how to address consistent and safe messaging on
suicide and related behaviors in their curricula.
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Objective 6.2: Partner with firearm dealers and gun owners to incorporate suicide
awareness as a basic tenet of firearm safety and responsible firearm ownership.
Objective 6.3: Develop and implement new safety technologies to reduce access to
lethal means.
Objective 7.2: Provide training to mental health and substance abuse providers on
the recognition, assessment, and management of at-risk behavior, and the delivery of
effective clinical care for people with suicide risk.
Objective 7.3: Develop and promote the adoption of core education and training
guidelines on the prevention of suicide and related behaviors by all health
professions, including graduate and continuing education.
Objective 7.4: Promote the adoption of core education and training guidelines on the
prevention of suicide and related behaviors by credentialing and accreditation bodies.
Objective 7.5: Develop and implement protocols and programs for clinicians and
clinical supervisors, first responders, crisis staff, and others on how to implement
effective strategies for communicating and collaboratively managing suicide risk.
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Objective 8.2: Develop and implement protocols for delivering services for individuals
with suicide risk in the most collaborative, responsive, and least restrictive settings.
Objective 8.3: Promote timely access to assessment, intervention, and effective care
for individuals with a heightened risk for suicide.
Objective 8.4: Promote continuity of care and the safety and well-being of all patients
treated for suicide risk in emergency departments or hospital inpatient units.
Objective 8.6: Establish linkages between providers of mental health and substance
abuse services and community-based programs, including peer support programs.
GOAL 9. Promote and implement effective clinical and professional practices for
assessing and treating those identified as being at risk for suicidal behaviors.
Objective 9.1: Adopt, disseminate, and implement guidelines for the assessment of
suicide risk among persons receiving care in all settings.
Objective 9.2: Develop, disseminate, and implement guidelines for clinical practice
and continuity of care for providers who treat persons with suicide risk.
Objective 9.3: Promote the safe disclosure of suicidal thoughts and behaviors by
all patients.
Objective 9.4: Adopt and implement guidelines to effectively engage families and
concerned others, when appropriate, throughout entire episodes of care for persons
with suicide risk.
Objective 9.5: Adopt and implement policies and procedures to assess suicide
risk and intervene to promote safety and reduce suicidal behaviors among patients
receiving care for mental health and/or substance use disorders.
Objective 9.6: Develop standardized protocols for use within emergency departments
based on common clinical presentation to allow for more differentiated responses
based on risk profiles and assessed clinical needs.
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GOAL 10. Provide care and support to individuals affected by suicide deaths and
attempts to promote healing and implement community strategies to help prevent
further suicides.
Objective 10.1: Develop guidelines for effective comprehensive support programs
for individuals bereaved by suicide, and promote the full implementation of these
guidelines at the state/territorial, tribal, and community levels.
Objective 10.5: Provide health care providers, first responders, and others with care
and support when a patient under their care dies by suicide.
Objective 11.3: Improve and expand state/territorial, tribal, and local public
health capacity to routinely collect, analyze, report, and use suicide-related data to
implement prevention efforts and inform policy decisions.
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Objective 11.4: Increase the number of nationally representative surveys and other
data collection instruments that include questions on suicidal behaviors, related risk
factors, and exposure to suicide.
Objective 13.3: Examine how suicide prevention efforts are implemented in different
states/territories, tribes, and communities to identify the types of delivery structures
that may be most efficient and effective.
Objective 13.4: Evaluate the impact and effectiveness of the National Strategy for
Suicide Prevention in reducing suicide morbidity and mortality.
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GOAL OR OBJECTIVE
Notes
2001 2012
Goal 1 Increase awareness that suicide Goal 2 The goal was expanded to address a
is a public health problem that is broad range of communication efforts
preventable. targeting various audiences.
1.1 Increase the number of states in which 2.1 and The objective was expanded to focus on
public information campaigns designed 2.4 changing the knowledge, attitudes, and
to increase public knowledge of suicide behaviors of various audiences.
prevention reach at least 50 percent of
the state's population.
1.2 Establish regular national congresses 1.1 The objective was revised to encourage
on suicide prevention designed to foster the integration of suicide prevention
collaboration with stakeholders on into the values, culture, leadership, and
prevention strategies across disciplines work of a wide range of organizations
and with the public. and programs.
1.4 Increase the number of public 2.3 and The objective was modified to support
and private institutions active in 4.3 an increase in all types of online
suicide prevention that are involved communication efforts. The related
in collaborative dissemination of Objective 4.3 focuses on guidelines
information on the World Wide Web. addressing the safety of online content.
Goal 2 Develop broad-based support for suicide Goal 1 The wording was revised: “Integrate and
prevention. coordinate suicide prevention activities
across multiple sectors and settings.”
2.1 Expand Federal Steering Group (FSG) Achieved The FSG was expanded and is now
to improve federal coordination, help and 1.3 called the Federal Working Group.
implement the NSSP, and coordinate The objective was revised to focus on
future revisions. sustaining and strengthening federal
collaborations.
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GOAL OR OBJECTIVE
Notes
2001 2012
2.2 By 2002, establish public-private Achieved The partnership was formed as the
partnerships to advance and coordinate at National Action Alliance for Suicide
implementation of NSSP. national Prevention. The objective was expanded
level and to support similar efforts at the state/
1.4 territorial, tribal, and local levels.
2.3 Increase the number of national 1.1 The objective now addresses the
professional, voluntary, and other integration of suicide prevention into
groups that integrate suicide prevention the values, culture, leadership, and
into ongoing programs and activities. work of a wide range of organizations
and programs with a role to support
suicide prevention activities.
Goal 3 Goal 3: Develop and implement Goal 3 The focus of the goal was broadened
strategies to reduce the stigma and 3.2 to promote greater knowledge of
associated with being a consumer of protective factors and of factors
mental health, substance abuse, and that promote wellness and recovery.
suicide prevention services. Reducing prejudice and discrimination
is addressed in Objective 3.2.
3.1 By 2005, increase the proportion of the 3.2 Addressed in Objective 3.2, which
public that views mental and physical focuses on reducing the prejudice and
health as equal and inseparable discrimination associated with suicide
components of overall health. and suicide-related behaviors.
3.2 By 2005, increase the proportion of the 3.2 and (see above) Also addressed in Objective
public that views mental disorders as 3.3 3.3, which focuses on promoting the
real illnesses that respond to specific understanding that recovery from mental
treatments. and substance use disorders is possible.
3.4 By 2005, increase the proportion of 8.3 The new Objective 8.3 promotes timely
those suicidal persons with underlying access to assessment, intervention,
disorders who receive appropriate and effective care for individuals with a
mental health treatment. heightened risk for suicide.
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GOAL OR OBJECTIVE
Notes
2001 2012
Goal 4 Develop and implement community- Goal 5 The revised goal addresses the
based suicide prevention programs. development, implementation, and
monitoring of programs that promote
wellness and prevent suicide and
related behaviors.
4.1 By 2005, increase the proportion of 5.1 Nearly all states have a suicide
states with comprehensive suicide prevention plan, but there is much
prevention plans that a.) coordinate variation among plans. Objective 5.1
across government agencies, b.) involve supports improvements to the plans.
the private sector, and c.) support plan
development, implementation, and
evaluation in their communities.
4.2 By 2005, increase the proportion of 5.2 The new Objective 5.2 includes
school districts and private school programs conducted in various settings,
associations with evidence-based including schools, which were previously
programs designed to address serious addressed in separate objectives.
childhood and adolescent distress and
prevent suicide.
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GOAL OR OBJECTIVE
Notes
2001 2012
4.8 By 2005, develop one or more training Achieved The Suicide Prevention Resource Center
and technical resource centers to build was established in 2002.
capacity for states and communities
to implement and evaluate suicide
prevention programs.
Goal 5 Promote efforts to reduce access to Goal 6 The goal was revised to focus on
lethal means and methods of self-harm. reducing access to lethal means and
methods among individuals with suicide
risk.
5.1 By 2005, increase the proportion of 6.1 The wording was revised: “Encourage
primary care clinicians, other health providers who interact with individuals
care providers, and health and safety at risk for suicide to routinely assess for
officials who routinely assess the access to lethal means.”
presence of lethal means (including
firearms, drugs, and poisons) in the
home and educate about actions to
reduce associated risks.
5.2 By 2005, expose a proportion of 2.1 Public information campaigns and other
households to public information communications efforts, including those
campaign(s) designed to reduce the addressing lethal means, are discussed
accessibility of lethal means, including in Objective 2.1.
firearms, in the home.
5.3 By 2005, increase the proportion of 3.2 and This is now addressed in Objective 3.2,
the public that views consumers of 3.3 which focuses on reducing prejudice
mental health, substance abuse, and and discrimination associated with
suicide prevention services as pursuing behavioral health disorders, and in
fundamental care and treatment for Objective 3.3, which focuses on
overall health. promoting the understanding that
recovery is possible.
5.4 By 2005, develop guidelines for safer 7.3 The objective is covered in Objective
dispensing of medications for individuals 7.3, which promotes the development
at heightened risk of suicide. and adoption of training guidelines for
all health professions.
5.5 By 2005, improve automobile design to 6.3 The objective was broadened to address
impede carbon monoxide-mediated suicide. all types of safety technologies.
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GOAL OR OBJECTIVE
Notes
2001 2012
Goal 6 Implement training for recognition of Goal 7 The wording was revised: “Provide
at-risk behavior and delivery of effective training to community and clinical
treatment. service providers on the prevention of
suicide and related behaviors.”
6.1 By 2005, define minimum course 7.3 The objective was broadened to address
objectives for providers of nursing the education and training in all health
care in assessment and management professions and to include graduate and
of suicide risk and identification continuing education.
and promotion of protective factors.
Incorporate this material into curricula
for nursing care providers at all
professional levels.
6.4 By 2005, increase the proportion 7.1 The new Objective 7.1 addresses the
of clergy who have received training training of all community providers.
in identification of and response to
suicide risk and behaviors and the
differentiation of mental disorders and
faith crises.
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2012 NATIONAL STRATEGY FOR SUICIDE PREVENTION
GOAL OR OBJECTIVE
Notes
2001 2012
6.7 By 2005, increase the proportion of 7.1 (see above)
divorce and family law and criminal
defense attorneys who have received
training in identifying and responding to
persons at risk for suicide.
6.9 By 2005, increase the number of 7.4 The objective was revised to promote
recertification or licensing programs the adoption of core education and
in relevant professions that require or training guidelines on the prevention
promote competencies in depression of suicidal self-directed violence and
assessment and management and related behaviors by credentialing and
suicide prevention. accreditation bodies.
Goal 7 Develop and promote effective clinical Goal 8 The goal was revised to promote suicide
and professional practices. prevention as a core component of
health care services.
7.1 By 2005, increase the proportion of 8.4 The objective was revised to promote
patients treated for self-destructive continuity of care and the safety and
behavior in hospital emergency well-being of all patients treated for
departments that pursue the proposed suicide risk in emergency departments
mental health follow-up plan. or hospital inpatient units.
7.2 By 2005, develop guidelines for 9.1 The objective was broadened to
assessment of suicidal risk among address the adoption of guidelines for
persons receiving care in primary health the assessment of suicide risk among
care settings, emergency departments, persons receiving care in all settings.
and specialty mental health and
substance abuse treatment centers.
7.3 By 2005, increase the proportion of 9.5 The wording was revised: “Adopt and
specialty mental health and substance implement policies and procedures
abuse treatment centers that have to assess suicide risk and intervene
policies, procedures, and evaluation to promote safety and reduce suicidal
programs designed to assess suicide behaviors among patients receiving
risk and intervene to reduce suicidal care for mental and/or substance use
behaviors among their patients. disorders.”
7.4 By 2005, develop guidelines for aftercare 9.2 The objective was broadened to address
treatment programs for individuals guidelines for clinical practice and
exhibiting suicidal behavior (including continuity of care for all providers who
those discharged from inpatient treat persons with suicide risk.
facilities). Implement these guidelines in
a proportion of these settings.
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GOAL OR OBJECTIVE
Notes
2001 2012
7.5 By 2005, increase the proportion 10.5 The objective was slightly revised:
of those who provide key services to “Provide health care providers, first
suicide survivors (e.g., emergency responders, and others with care and
medical technicians, firefighters, law support when a patient under their care
enforcement officers, funeral directors, dies by suicide.”
clergy) who have received training that
addresses their own exposure to suicide.
7.6 By 2005, increase the proportion of 8.3 Addressed in Objective 8.3, which
patients with mood disorders who focuses on promoting timely access to
complete a course of treatment or assessment, intervention, and effective
continue maintenance treatment as care for individuals with a heightened
recommended. risk for suicide.
7.8 By 2005, develop guidelines for 9.4 The wording was revised: “Adopt and
providing education to family members implement guidelines to effectively
and significant others of persons engage families and concerned others,
receiving care for the treatment when appropriate, throughout entire
of mental health and substance episodes of care for persons with
abuse disorders with risk of suicide. suicide risk.”
Implement the guidelines in facilities
including general and mental hospitals,
mental health clinics, and substance
abuse treatment centers.
7.9 By 2005, incorporate screening for N/A Screening for depression and alcohol
depression, substance abuse, and misuse have now been endorsed
suicide risk as a minimum standard by the United States Preventative
of care for assessment in primary care Services Task Force (USPSTF) and are
settings, hospice, and skilled nursing now covered as preventative services
facilities for all federally supported under Medicare. The PHQ-9 has been
health care programs (e.g., Medicaid, incorporated into the CMS Minimum
CHAMPUS/TRICARE, CHIP, Medicare). Data Set for nursing home assessment.
7.10 By 2005, include screening for N/A Screening for depression and alcohol
depression, substance abuse, and misuse have now been endorsed by
suicide risk as measurable performance the USPSTF and are now covered as
items in the Health Plan Employer Data preventative services under Medicare.
and Information Set.
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2012 NATIONAL STRATEGY FOR SUICIDE PREVENTION
GOAL OR OBJECTIVE
Notes
2001 2012
Goal 8 Improve access to and community 8.6, 8.7, Objective 8.6 addresses linkages
linkages with mental health and and 8.8 between behavioral health service
substance abuse services. providers and community-based
programs. Objective 8.7 addresses
coordination between behavioral health
systems and local crisis centers.
Objective 8.8 addresses collaborations
between emergency departments and
other health care providers.
8.1 By 2005, increase the number of states 5.4 and Parity laws are addressed in Objective
that require health insurance plans 1.5 5.4, which supports efforts to increase
to cover mental health and substance access to and delivery of effective
abuse services on par with coverage for programs and services for mental and
physical health. substance use disorders. Objective 1.5
promotes the integration of suicide
prevention into all relevant health care
reform efforts.
8.2 By 2005, increase the proportion of 8.3 Covered in Objective 8.3, which
counties (or comparable jurisdictions) promotes timely access to assessment,
with health and/or social services intervention, and effective care for
outreach programs for at-risk individuals with a heightened risk for
populations that incorporate mental suicide.
health services and suicide prevention.
8.3 By 2005, define guidelines for mental N/A The revised objectives are broad and
health (including substance abuse) not focused on specific settings or
screening and referral of students in populations.
schools and colleges. Implement those
guidelines in a proportion of school
districts and colleges.
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GOAL OR OBJECTIVE
Notes
2001 2012
8.6 By 2005, for adult and juvenile N/A (see above)
incarcerated populations, define
national guidelines for mental health
screening, assessment, and treatment
of suicidal individuals. Implement the
guidelines in correctional institutions,
jails, and detention centers.
8.7 By 2005, define national guidelines 10.1 The wording was revised: “Develop
for effective comprehensive support guidelines for effective comprehensive
programs for suicide survivors. support programs for individuals
Increase the proportion of counties (or bereaved by suicide and promote the
comparable jurisdictions) in which the full implementation of these guidelines
guidelines are implemented. at the state/territorial, tribal, and
community levels.”
8.8 By 2005, develop quality care/ Goal 8, The incorporation of suicide prevention
utilization management guidelines 8.5 into continuous quality improvement
for effective response to suicidal risk efforts is an important theme in Goal 8
or behavior and implement these and is addressed in Objective 8.5.
guidelines in managed care and health
insurance plans.
Goal 9 Improve reporting and portrayals of Goal 4 Reworded to include online content:
suicidal behavior, mental illness, and “Promote responsible media reporting
substance abuse in the entertainment of suicide, accurate portrayals of
and news media. suicide and mental illnesses in the
entertainment industry, and the safety
of online content related to suicide.”
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2012 NATIONAL STRATEGY FOR SUICIDE PREVENTION
GOAL OR OBJECTIVE
Notes
2001 2012
9.4 By 2005, increase the number of 4.4 The objective was broadened to include
journalism schools that include in their mass communication schools.
curricula guidance on the portrayal and
reporting of mental illness, suicide, and
suicidal behaviors.
Goal 10 Promote and support research on Goal 12 Promote and support research on
suicide and suicide prevention. suicide prevention.
10.1 By 2002, develop a national suicide 12.1 and The Action Alliance’s Research
research agenda with input from 12.2 Prioritization Task Force is developing
survivors, practitioners, researchers, a national research agenda. The
and advocates. new Objective 12.2 addresses the
dissemination and use of the research
agenda.
10.2 By 2005, increase funding (public and 13.1 and Objective 13.1 supports the
private) for suicide prevention research, 13.2 evaluation of suicide prevention
for research on translating scientific interventions. Objective 13.2 promotes
knowledge into practice, and for the assessment, synthesis, and
training of researchers in suicidology. dissemination of the evidence obtained
via these evaluations.
10.3 By 2005, establish and maintain a 12.3 and A best practices registry has
registry of prevention activities with 12.4 been established by the Suicide
demonstrated effectiveness for suicide Prevention Resource Center. The new
or suicidal behaviors. Objective 12.3 focuses on the timely
dissemination of suicide prevention
research findings. The new Objective
12.4 focuses on the development of a
repository of research resources.
10.4 By 2005, perform scientific evaluation 13.1 and Objective 13.1 supports the
studies of new or existing suicide 13.2 evaluation of suicide prevention
prevention interventions. interventions. Objective 13.2 promotes
the assessment, synthesis, and
dissemination of the evidence obtained
via these evaluations.
Goal 11 Improve and expand surveillance Goal 11 The wording was revised: “Increase
systems. the timeliness and usefulness of
national surveillance systems relevant
to suicide prevention, and improve the
ability to collect, analyze, and use this
information for action.”
11.1 By 2005, develop and refine 11.2 Addressed in Objective 11.2, focuses
standardized protocols for death scene on improving the usefulness and quality
investigations and implement these of suicide-related data.
protocols in counties (or comparable
jurisdictions).
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GOAL OR OBJECTIVE
Notes
2001 2012
11.2 By 2005, increase the proportion of 11.2 (see above)
jurisdictions that regularly collect and
provide information for follow-back
studies on suicides.
11.5 By 2005, increase the number of 11.3 The objective was broadened to promote
states that produce annual reports the improvement and expansion of
on suicide and suicide attempts, state/territorial, tribal, and local public
integrating data from multiple state health capacity to routinely collect,
data management systems. analyze, report, and use suicide-related
data to implement prevention efforts
and inform policy decisions.
11.6 By 2005, increase the number of 11.4 The objective was broadened to address
nationally representative surveys that other data collection instruments and
include questions on suicidal behavior. systems, and to include questions on
risk factors and exposure to suicide.
11.7 By 2005, implement pilot projects in 11.3 Addressed in Objective 11.3, which
several states that link and analyze seeks to expand the capacity to
information related to self-destructive collect, analyze, report, and use
behavior derived from separate data suicide-related data.
systems, including law enforcement
agencies, emergency medical services,
and hospitals.
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2012 NATIONAL STRATEGY FOR SUICIDE PREVENTION
Objective 8.1: Promote the adoption of “zero suicides” as an aspirational goal by health care and
community support systems that provide services and support to defined patient populations.
Objective 8.2: Develop and implement protocols for delivering services for individuals with suicide
risk in the most collaborative, responsive, and least restrictive settings.
Objective 8.5: Encourage health care delivery systems to incorporate suicide prevention and
appropriate responses to suicide attempts as indicators of continuous quality improvement efforts.
Objective 9.3: Promote the safe disclosure of suicidal thoughts and behaviors by all patients.
Objective 9.6: Develop standardized protocols for use within emergency departments based on
common clinical presentation to allow for more differentiated responses based on risk profiles and
assessed clinical needs.
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2012 NATIONAL STRATEGY FOR SUICIDE PREVENTION
Objective 9.7: Develop guidelines on the documentation of assessment and treatment of suicide risk,
and establish a training and technical assistance capacity to assist providers with implementation.
Objective 10.2: Provide appropriate clinical care to individuals affected by a suicide attempt or
bereaved by suicide, including trauma treatment and care for complicated grief.
Objective 10.3: Engage suicide attempt survivors in suicide prevention planning, including support
services, treatment, community suicide prevention education, and the development of guidelines and
Objective 10.4: Adopt, disseminate, implement, and evaluate guidelines for communities to
respond effectively to suicide clusters and contagion within their cultural context, and support
territories, tribes, and communities to identify the types of delivery structures that may be most
Objective 13.4: Evaluate the impact and effectiveness of the National Strategy for Suicide Prevention
in reducing suicide morbidity and mortality.
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2012 NATIONAL STRATEGY FOR SUICIDE PREVENTION
1989: U.S.
1967: National Department of Health
Institute of Mental and Human Services
Health (NIMH) 1971: The
(HHS) publishes
establishes Center journal Suicide
Report of the
for Studies of and Life
Secretary’s Task Force
Suicide Prevention. Threatening
on Youth Suicide.
Behavior
publishes its 1989: AAS holds its
first issue. first “Healing After
Suicide” conference.
1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 19
1987: American
1973: NIMH publishes Foundation for
Suicide Prevention in Suicide Prevention
the 70s. (AFSP) founded.
1968: First national
1960: International
conference on
Association for
suicidology held in
Suicide Prevention
Chicago, Illinois.
founded.
1968: American
Association of
Suicidology (AAS)
founded.
1990: SAVE is
incorporated.
Suicide prevention efforts in the United States started in the 1950s, through the pioneering efforts of
a small group of dedicated clinicians interested in better understanding suicide and its prevention.
These early efforts were expanded upon in the 1980s with the support and passion of individuals who
had been bereaved by a suicide loss. With limited funding and formal organization, these individuals
and their grassroots organizations set out to place suicide on the national agenda. Their combined
efforts over time culminated with the release of the 2001 National Strategy for Suicide Prevention.
These dedicated advocates, organizations, and communities have remained at the forefront of suicide
prevention activities nationwide.
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85 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012
PAGE 95
First Steps
In 1958, the first suicide prevention center in the United States opened in Los Angeles, California, with
funding from the U.S. Public Health Service. Other crisis intervention centers followed. In 1966, the
Center for Studies of Suicide Prevention (later the Suicide Research Unit) was established at the National
Institute of Mental Health (NIMH) of the National Institutes of Health (NIH). This was followed by the
creation of national nonprofit organizations dedicated to the cause of suicide prevention.
In 1970, NIMH convened a task force in Phoenix, Arizona, to discuss the status of suicide prevention in
the United States. NIMH presented the findings in the 1973 report Suicide Prevention in the 70s, which
also identified future directions and priorities.111 In 1983, the Centers for Disease Control and Prevention
(CDC) established a violence prevention unit that brought public attention to a disturbing increase in
youth suicide rates. In response, the Secretary of the U.S. Department of Health and Human Services
(HHS) established a Task Force on Youth Suicide, which reviewed the existing evidence and issued
recommendations in 1989.112
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each person.
2. Suicide is not solely the result of illness or inner conditions. The feelings of
hopelessness that contribute to suicide can stem from societal conditions and attitudes.
Therefore, everyone concerned with suicide prevention shares a responsibility to help
change attitudes and eliminate the conditions of oppression, racism, homophobia,
discrimination, and prejudice.
3. Some groups are disproportionately affected by these societal conditions, and some are
at greater risk for suicide.
5. The success of this strategy ultimately rests with individuals and communities across the
United States.
A year later, the HHS Secretary formed a Federal Steering Group to coordinate efforts and ensure
resources for the development of the national strategy. The group brought together individuals and
organizations from the public and private sectors to collaborate in this effort and sought input through
four strategically located national public hearings. These efforts culminated with the release of the National
Strategy for Suicide Prevention in 2001.6
The National Strategy for Suicide Prevention (National Strategy) set forth an ambitious agenda, consisting
of 11 goals and 68 objectives, organized under the AIM framework described in the Surgeon General’s Call
to Action. The document was meant to serve as a wide-ranging “catalyst for social change, with the power
to transform attitudes, policies, and services (p. 27).”6 For the broader suicide prevention community, the
National Strategy provided a common point of reference and a resource for advocacy at the state and local
levels, while directing more attention to the needs of those affected by suicide.
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2012 NATIONAL STRATEGY FOR SUICIDE PREVENTION
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2012 NATIONAL STRATEGY FOR SUICIDE PREVENTION
Program Initiatives
In 2001, SAMHSA established the country’s first program with the mission of effectively reaching
and serving all persons at risk of suicide in the United States through a national network of local,
certified crisis call centers. This program, now called the National Suicide Prevention Lifeline (800–
273–TALK/8255) serves as a central switchboard, seamlessly connecting callers to a crisis center
geographically nearest the caller from among a national network of more than 150 crisis centers in 49
states. It provides services in English and Spanish, 24 hours a day, 7 days a week. It also includes a feature
allowing callers to press “1” and be connected to a VA crisis center. The Lifeline also operates a website
(www.suicidepreventionlifeline.org) and works closely with social networking websites. In October 2011,
the Lifeline answered its 3 millionth call.
The Lifeline used evaluation results to introduce best practice standards used across the network. To
improve service quality, SAMHSA funded two evaluations of network crisis center practices in 2003–04.
These evaluations culminated in groundbreaking findings for the field, released in 2005 and published in
2007.114, 115 These findings demonstrated both effective crisis center practices (e.g., significant reductions
in caller distress and suicidal risk) and needs for improvement (e.g., better risk assessment, more uniform
approaches for callers at imminent risk of suicide, a need to monitor calls and more follow up with callers).
The creation of the first national resource center on suicide prevention was another important
accomplishment. Established by SAMHSA in 2002, the Suicide Prevention Resource Center (SPRC)
conducts a broad range of activities intended to improve the development, implementation, and evaluation
of suicide prevention programs and practices. The center disseminates information, products, and services
to various audiences through its website (www.sprc.org), online and face-to-face training programs,
webinars, and direct consultation and support from its expert staff. SPRC also maintains an online library
and clearinghouse of suicide prevention information and a registry of evidence-based programs and best
practice recommendations.
The 2001 National Strategy specifically called for the creation of a national violent death reporting system
to gather information from several data sources that were not otherwise linked. In Fiscal Year 2002,
Congress appropriated funds for the development and implementation of the National Violent Death
Reporting System (NVDRS). Originally implemented in six states, the system was extended to a total of
18 states in Fiscal Year 2009, via a congressional appropriation of $3.5 million. The system collects data on
violent deaths from four primary sources: death certificates, police reports, medical examiner and coroner
reports, and crime laboratories. Data are available for public use through the Web-Based Injury Statistics
Query and Reporting System (WISQARS, at www.cdc.gov/injury/wisqars/index.html).
The 2001 National Strategy also called for the development of comprehensive state suicide prevention
plans that would coordinate across government agencies; involve the private sector; and support plan
development, implementation, and evaluation in communities. Today, nearly all states have a suicide
prevention plan in place and some have formed public-private partnerships to advance their plans.
Although these suicide prevention plans vary in terms of the groups they serve, involvement of the private
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sector, and resources available for services, their development represents an important first step and
achievement in the field of suicide prevention.
Recent Developments
Recent milestones in the history of suicide prevention in the United States include the formation of the
National Action Alliance for Suicide Prevention, in 2010, and the revision of the National Strategy in 2012.
These milestones represent continuing progress toward the prevention of suicide in this country. For more
on these recent developments, see the Introduction section.
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suicide in the AI/AN population: 40.79 deaths per 100,000.1 Although suicide rates vary widely among
individual tribes, it is estimated that 14 to 27 percent of AI/AN adolescents have attempted suicide.21-23
Research indicates that cultural continuity,116 high levels of cultural spiritual orientation,117 and
connectedness to family and friends21 are protective factors for suicidal behaviors among AI/AN
populations. Specific risk factors particular to this group include alcohol and other substance use,118
discrimination,119, 120 limited mental health services access and use,121, 122 and historical trauma.123, 124
Findings from the Adverse Childhood Experiences (ACE) study suggest that there is a strong and positive
correlation between the number of adverse events in a child’s life and the probability for negative outcomes
during adulthood.125 In reservation settings, AI/AN youth have considerable exposure to suicide and
may be at particular risk for contagion.126 Much of the research available on AI/AN racial and ethnic
disparities does not include urban (non-reservation) areas, where a majority (78 percent) of Native people
in the United States live.127 Compared with other racial and ethnic groups, few resources are devoted to
the health needs of the urban AI/AN population,128 and many have experienced losses of community,
language, and ethnic identity.129
Several federal initiatives, such as the Substance Abuse and Mental Health Services Administration
(SAMHSA) Garrett Lee Smith and Native Aspirations programs and the Indian Health Service (IHS)
Methamphetamine and Suicide Prevention Initiative, support suicide prevention efforts among AI/
AN populations. AI/AN communities have implemented a range of culturally specific prevention and
intervention approaches to address the holistic needs of families and individuals affected by suicide
and other health disparities. These efforts include reducing risk behaviors (e.g., substance use, bullying,
violence) and promoting protective factors (e.g., cultural practices, community connectedness and
healing, improved access to appropriate services, skills enhancement). Recent efforts have included the
development of crisis response protocols aimed at ensuring that available services and traditional supports
are interconnected. Many tribes have also adapted mainstream suicide prevention programs, including
trainings, crisis lines, mentoring, and school-based programs, for use in local AI/AN communities.
Many efforts are underway to better document the effectiveness of these holistic approaches in Native
communities. A comprehensive, public health-based prevention program in a southwestern tribal
community showed significant reduction in suicidal acts among youth.64 The American Indian Life Skills
Development program, a school-based curriculum for AI/AN youth aged 14 to 19, showed reductions in
feelings of hopelessness and increases in problem-solving skills.130 Positive youth development programs,
such as Project Venture, while recognized as an evidence-based approach for substance use prevention,
also showed positive results in terms of suicide prevention. Many of the specific tactics that suicide
prevention research points to as effective (e.g., increased social integration, connection building) have
been a part of Project Venture for 20 years.131
Community-based surveillance systems, such as the one developed by the White Mountain Apache,
demonstrate that tribal-specific surveillance can identify unique risk and protective factors for particular
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populations to guide local suicide prevention programs.132, 133 Practice-based evidence also plays an
important role and complements evidence-based practices in addressing suicide and other health issues
among AI/AN populations.
Resources
Adolescent Suicide Prevention Program Manual: A Public Health Model for Native American
Communities, 2011
SPRC
www.sprc.org/library/AdolescentSP_ProgramManuaPH_ModelNA_Communities.pdf
The Adolescent Suicide Prevention Program (1989–2005) significantly lowered youth suicide rates in
a Native community in the Southwest United States. This manual outlines methods for community
involvement, culturally framed public health approaches, outreach efforts, behavioral health programs,
program evaluation, and sustainability.
Ensuring the Seventh Generation: A Youth Suicide Prevention Toolkit for Tribal Child Welfare
Programs, 2009
National Indian Child Welfare Association (NICWA)
www.nicwa.org/YouthSuicidePreventionToolkit/YSPToolkit.pdf
This toolkit for tribal child welfare workers and care providers discusses risk factors, warning signs,
prevention and intervention strategies that can be applied in child welfare agencies, and mobilization of
support networks for particular children.
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2012 NATIONAL STRATEGY FOR SUICIDE PREVENTION
To Live To See the Great Day That Dawns: Preventing Suicide by American Indian and Alaska Native
Youth and Young Adults, 2010
SAMHSA, HHS
www.sprc.org/library/Suicide_Prevention_Guide.pdf
This guide supports AI/AN communities in developing effective, culturally appropriate, and
comprehensive suicide prevention planning and postvention responses for youth and young adults.
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responders (e.g., police, emergency medical professionals, clergy, funeral professionals) and should receive
information about where to get additional help if and when he or she is ready to seek it. As different people
will use different types of resources, often at different points in their grieving process, a second goal should
encompass the development of a variety of support services within local communities. These include, but
are not limited to, educational and self-help literature about grief after suicide, survivor outreach teams,
face-to-face and online support groups, and referral assistance in finding clinicians who understand grief,
trauma, and the special problems of those who have been bereaved by suicide. Increased education about
the impact of suicide and the needs of the bereaved by suicide should be included in the training of first
responders and mental health and substance use professionals. And lastly, the national suicide research
agenda should include studies that will expand knowledge of the impact of suicide on those left behind,
and of interventions that will be effective in helping a diverse range of people who are exposed to the
sometimes overwhelming impact of suicide.39
Resources
American Association of Suicidology (AAS)
www.suicidology.org/web/guest/suicide-loss-survivors
The survivor pages on the AAS website include the e-newsletter Surviving Suicide, a directory of survivor
support groups, a resource list, and materials for clinicians who have lost a patient and/or family member
to suicide. AAS has also produced the SOS Handbook, a quick reference booklet for suicide survivors.
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SAVE’s website survivor section provides information on coping with suicide loss, talking with children
about suicide, and responding to person who has been bereaved by suicide, as well as networking
resources such as a survivor groups directory and the Bereavement Caregiver Blog. Its print materials
include the booklet Suicide: Coping With the Loss of a Friend or Loved One and the book Suicide Survivors:
A Guide For Those Left Behind.
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Experts theorize that jail suicides may have two primary causes: (1) jail environments are conducive
to suicidal behaviors; and (2) the inmate faces a crisis situation.148 Studies conducted by the National
Center on Institutions and Alternatives and commissioned by the U.S. Department of Justice (DoJ)
recommend that all sites develop and implement comprehensive policies and programming addressing
suicide prevention, intervention, and care in the aftermath of a suicide death or attempt. These policies
and programs should include: initial and annual training for all direct care, medical, and mental health
personnel; initial intake and ongoing assessment of incarcerated persons; enhanced communication
along the continuum of justice system; levels of supervision for persons at risk of self-harm and
suicide; appropriate suicide-resistant housing; intervention; reporting; mortality/morbidity incident
review; and critical incident stress debriefing.146 Because inmates can be at risk for suicide at any point
during confinement, the biggest challenge for those who work in the justice system is to view the issue
as requiring a continuum of comprehensive suicide prevention services aimed at the collaborative
identification, continued assessment, and safe management of individuals at risk for suicidal behaviors.
A dramatic reduction in the rate of suicide within county jails throughout the United States in the past 20 years
has been attributed to increased staff training, better identification of inmates who may be at risk for suicidal
behaviors, and the implementation of comprehensive programming.32 Recent efforts for suicide prevention
for youth involved in the juvenile justice system include: targeting state-level juvenile justice agency directors/
administrators with training developed to encourage comprehensive policy development; training direct care
staff working in juvenile facilities; improving data collection and research within the population; increasing
collaboration between mental health and juvenile justice systems; and improving policy and programming.149
Resources
Endangered Youth: A Report on Suicide Among Adolescents Involved with the Child Welfare and
Juvenile Justice Systems, 2006
Connecticut Center for Effective Practices
www.chdi.org/endangeredyouth
This report offers an interdisciplinary framework that addresses the suicide risk for children, youth,
and their families involved in the child welfare and juvenile justice systems. Case studies illustrate the
challenges confronting families, communities, and professionals, while offering opportunities for learning
and development of effective service delivery.
Ensuring the Seventh Generation: A Youth Suicide Prevention Toolkit for Tribal Child Welfare
Programs, 2009
NICWA
www.nicwa.org/YouthSuicidePreventionToolkit/YSPToolkit.pdf
Intended for tribal child welfare workers and care providers, this toolkit discusses suicide risk factors
associated with children in child welfare; warning signs caseworkers and care providers should watch
for; suicide prevention and intervention strategies that can be applied in child welfare agencies; and
mobilization of support networks around particular children.
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Resources
Cornell Research Program on Self-Injurious Behavior in Adolescents and Young Adults
www.crpsib.com
This program conducts research on self-injury in adolescents and young adults and translates the
knowledge gained into resources and tools for understanding and treating self-injury. The website
summarizes the program’s work and provides links and resources with information on preventing,
detecting, and treating self-injurious behavior.
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silence, prejudice, and misunderstanding about the subject of suicide create barriers to open discussion.
This culture of “don’t ask, don’t tell” can foster rejection, social isolation, and even discrimination if the
suicide attempt is known. Spouses, parents, and others need help adjusting, as well as tools, evidence-based
information, and programs for supporting people who survive an attempt.
Research suggests that even simple efforts to challenge isolation and provide follow-up support to people
living in the community after an attempt can have a powerful impact and reduce future attempts.158
A program that used hand-written postcards with brief personal messages showed remarkable results
in reducing reattempt hospital admissions, revealing that a small amount of effort in the area of social
support may be very powerful.159 In addition, a growing number of programs that provide suicide attempt
survivors with self-help tools and social support show great promise in reducing isolation and empowering
people to manage their own suicide risk and mental health.
In the last 15 years, several organized efforts have emerged to learn from and serve the needs of people
who have attempted suicide outside the traditional clinical services sector. In October 2005, the first
National Conference for Survivors of Suicide Attempts, Health care Professionals, Clergy, and Laity was
held in Memphis, Tennessee. The summary report of that conference is one of the first documents to
articulate the perspectives of individuals who have attempted suicide.160 Two years later, in July 2007, the
National Suicide Prevention Lifeline (800–273–TALK/8255) sponsored a project that provided even more
specific and rich information to better serve the needs of this population.161
Simultaneously, across the nation and internationally, there has been a significant increase in the number
and variety of mental health consumer peer support and peer specialist services that may provide
meaningful ongoing supports for people who have survived suicide attempts. These programs, which
have been recognized as evidence-based practices by SAMHSA, provide social support that is not framed
in terms of crisis and that can be an important resource for personal mental health maintenance and
recovery.162 Such initiatives can empower and motivate people after an attempt, while at the same time
challenge prejudice and shame in the area of suicide. These efforts can also increase social support for
suicide reduction and contribute to increased funding and resources for preventing recurring attempts.
Although many communities are initiating programs and supports that can prevent people from
reattempting, more and better strategies are needed. Technical assistance efforts, combined with the
broad dissemination of resources and information to communities across America, have great potential
to reduce suicide death. Resources for attempt survivors, such as Stories of Hope and Recovery, developed
by SAMHSA and the National Suicide Prevention Lifeline (800–273–TALK/8255), hold promise for
reducing prejudice and for promoting collaborative approaches for treatment engagement with attempt
survivors. The After an Attempt brochure, distributed by SAMHSA, provides basic information for attempt
survivors, family, and providers in English and Spanish for distribution in hospitals. Increased resources,
peer support groups, web-based supports, informational DVDs, and trainings for health care providers
are needed to ensure that individuals who have attempted suicide, along with their families and friends,
receive the support, advice, and information they need to find the most direct path to recovery.
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Resources
American Association of Suicidology
www.suicidology.org/web/guest/suicide-attempt-survivors
AAS has a collection of resources for those who have survived a suicide attempt and are looking for
support and information. They include pamphlets, stories of others who have attempted suicide, and links
to research about attempt survivors.
Continuity of Care for Suicide Prevention and Research: Suicide Attempts and Suicide Deaths
Subsequent to Discharge from the Emergency Department or Psychiatry Inpatient Unit, 2010
SPRC
www.sprc.org/library/continuityofcare.pdf
This is a comprehensive report offering recommendations for the ongoing care of patients at risk for
suicide who have been treated in EDs and hospitals. It discusses 10 principles for improved continuity of
care and provides examples of seven integrated systems of care in the United States and Europe.
Cancers
Cancer is one of the most common physical illnesses associated with elevated suicide risk. The National
Cancer Institute has identified cancers of the mouth, throat, and lung as risk factors for suicidal
behaviors.163 While suicide risk tends to be highest in the first few months after diagnosis, risk remains
elevated in the first 5 years.164 Fear associated with how the disease is perceived and managed, rather
than the fear of death itself, is a frequent precipitator of suicidal behaviors.165 The consequences or side
effects of treatment can also result in psychological problems.166 Fatigue and/or exhaustion, some of the
most frequently reported side effects of cancer treatments, can be a risk factor for suicidal behaviors.167 In
addition, depression and anxiety are common in cancer patients. About 63 to 85 percent of individuals
with cancer who die by suicide meet criteria for severe depression, anxiety, and thought disorder.168
It is not always clear whether these types of mental disorders are triggered by the disease, occur as a
consequence of the disease, or are an adverse effect of the treatment itself.165
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Huntington’s disease and is thought to be a consequence of the disease itself, rather than a psychological
reaction to having a serious illness.170 In addition, anxiety disorders, obsessive-compulsive disorders,
psychosis, mania, aggression, irritability, impulsivity, and personality changes have all been reported in
patients with the disease.
Multiple Sclerosis: Studies confirm an increased risk of suicide among patients with multiple sclerosis.171
Lifetime prevalence rates of depression range from 37 to 54 percent, and the prevalence rate of depression
is almost three times the lifetime prevalence reported in the general population.172 Generalized anxiety
disorder, panic disorder, and bipolar affective disorder (manic episodes) are also present more frequently
in these patients.
Parkinson’s Disease: Parkinson’s disease is often associated with one or more psychiatric or cognitive
disorders, such as depression, psychosis, and dementia.173 Most of the observations support the hypothesis
that depression is a primary consequence of brain dysfunction, although situational factors may contribute
to mood changes to some extent.174 Suicide and suicide attempts are uncommon despite the fact that
the rates of suicidal ideation are elevated. Depression seems to be the most important predictor of
suicide ideation.
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Migraine: In general, patients with migraine are two to four times more likely to develop depression, two
to six times more likely to develop general anxiety disorder, five times more likely to develop obsessive-
compulsive disorder, and up to seven times more likely to develop panic disorder than the general
population. Furthermore, depressed patients are about three times more likely to develop migraine in their
lifetime. Migraine with an aura is believed to have a stronger association with psychiatric conditions than
migraine without an aura. The relationship between migraine and depression and anxiety appears to be
bidirectional, with each increasing the risk of the other condition. The risk of suicide ideation and attempts
is higher among migraine patients, especially in those who have migraine with aura.186
HIV/AIDS
Most studies among individuals living with HIV report lifetime prevalence of suicide attempts that range
from 22 to 50 percent.187 Individuals with AIDS were 44 times more likely to attempt suicide than those
without AIDS.188
While most studies report that persons living with HIV/AIDS have much higher suicide rates than the
general population or those with other life-threatening illnesses, studies have reported no significant
differences in suicide rates between HIV-infected individuals and other groups at risk for suicide, such
as injection drug users and psychiatric patients.189, 190 Hence, HIV status may not be the most relevant
factor related to suicide, but rather that other suicide risk factors that are common among HIV-infected
individuals play a more important role.191 Studies have shown that suicide attempts and suicide ideation
among people with HIV occur most often in those who have a previous psychiatric history and other
social and environmental risk factors for suicide.192 Mood, anxiety, substance abuse, and personality
disorders are prevalent among those with HIV.187
Arthritis
Arthritic disorders often co-occur with other physical conditions, especially chronic pain conditions
including back pain, migraine, and other chronic headaches.195 The association between arthritis and
problems such as anxiety, substance use, and personality disorders has been demonstrated in large,
population-based studies.196, 197 The relationship between arthritis and suicidal behavior may be largely
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explained by comorbid mental health disorders alone or in combination with other factors such as level of
pain and/or disability that are associated with a lower quality of life.198
Asthma
Adolescents with asthma are more likely to report depressive symptoms, panic attacks, suicide ideation
and behavior, and substance abuse when compared with those without asthma.199-201 It is not clear whether
the association between asthma and depressive and anxiety disorders, as well as with suicidal ideation and
behavior, results from a shared underlying process or from shared risk factors.
Resources
Medical Conditions Associated With Suicide Risk, Edited by A.L. Berman & M. Pompili, 2011
American Association of Suicidology
www.suicidology.org/web/guest/store
This book summarizes research on 25 medical conditions that are associated with suicide risk, such as
cancer, TBI, and HIV and AIDS. It outlines risk factors to assess patients and provides recommendations
for clinicians.
Mental Disorders
MOOD DISORDERS
Mood disorders are among the most common and may be the most life-threatening psychiatric illnesses.202
Major depressive disorder, also called major depression or unipolar disorder, is characterized by a
combination of symptoms, such as sadness and loss of interest or pleasure in once-pleasurable activities,
which interfere with everyday life. It has been estimated that 12 to 17 percent of individuals will experience
a major depressive episode within their lifetime.203 Although a person may experience only a single
episode, more often he or she may have several episodes throughout his or her life.
Bipolar disorders, also called manic-depressive illness, is characterized by dramatic mood swings, going
from an overly energetic “high” (mania) to sadness and hopelessness (depression). People with bipolar
disorders type I have had at least one manic episode along with periods of major depression. Those with
bipolar disorders type II have periods of high energy levels and impulsiveness that are not as extreme as
mania and also alternate with episodes of major depression. The estimated lifetime prevalence of bipolar
disorders is 1.3 to 5 percent.203
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More than 60 percent of suicidal deaths occur among individuals with mood disorders. Suicide risk is
particularly high among individuals with bipolar disorders, which is strongly associated with suicide
thoughts and behaviors. Over their lifetime, the vast majority (80 percent) of patients with bipolar
disorders have either suicidal ideation or ideation plus suicide attempts.24 In clinical samples, 14 to 59
percent of the patients have suicide ideation, and 25 to 56 percent attempt suicide at least once in their
lifetime.204 Approximately 15 to 19 percent of patients with bipolar disorders die from suicide. The suicide
rate among patients with bipolar disorders is estimated to be more than 25 times higher than the rate in
the general population.25
Several factors can increase the risk for suicide among patients who have mood disorders. These factors
include a recent suicide attempt and a severe major depressive episode, often accompanied by feelings of
hopelessness and guilt, a belief that that are few reasons for living, thoughts of suicide, agitation, insomnia,
appetite and weight loss, and psychotic features.205 Suicidal behaviors among mood disorder patients occur
almost exclusively during an acute, severe, major depressive episode.205
Among patients with major depressive disorder, risk factors for suicide include other comorbid psychiatric
conditions, such as post-traumatic stress disorder (PTSD), dependent personality disorder, borderline
personality disorder, and substance use disorders.206 Among those with bipolar disorders, risk factors
include a family history of suicide, early onset of bipolar disorders, increasing severity of affective
disorders, presence of mixed affective states, and abuse of alcohol or drugs.207
Major depressive disorder often fails to be recognized, diagnosed, or treated.203 It is believed that many
men in midlife who have the disorder do not seek treatment for their symptoms, and even when they do,
they often drop out of treatment before they reach remission.208 Evidence is mounting that individuals who
have had a stroke or heart attack and/or have chronic diabetes are likely to develop depression related to
their physical illnesses. Older individuals are particularly likely to do so.
Studies have shown that educating primary care providers in the assessment, treatment, and management
of depression leads to reductions in suicide. Appropriate acute and long-term treatment of depressive
disorders, including both pharmacological and nonpharmacological methods (especially cognitive
behavioral therapy), greatly reduces the risk of suicide and attempted suicide in this high-risk
population.205 Large-scale, long-term, European observational studies of former inpatients with bipolar
disorders show that long-term use of mood stabilizers reduces the risk of suicide, compared to patients
who stop taking medication. There is also some evidence that psychotherapies can improve compliance
and increase the effectiveness of pharmacotherapy, thereby possibly providing more protection against
suicide risk.205
ANXIETY DISORDERS
Anxiety disorders affect about 40 million American adults aged 18 and older (about 18 percent) in a given
year.209 Unlike the relatively mild, brief anxiety caused by a stressful event like speaking in public, anxiety
disorders last at least 6 months and can become worse if not treated. These disorders include the following:
social phobia, simple phobia, generalized anxiety disorder, panic disorder, agoraphobia, PTSD, and
obsessive-compulsive disorder (OCD).
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The presence of any anxiety disorder is significantly associated with suicidal ideation and suicide attempts.
Anxiety disorders commonly occur along with other mental or physical illnesses, including alcohol or
substance abuse, which may mask anxiety symptoms or make them worse. The presence of any anxiety
disorder in combination with a mood disorder is associated with a higher likelihood of suicide attempts in
comparison with a mood disorder alone.210 Among adults in the general population (i.e., not in the Armed
Forces or veterans), panic disorder and PTSD have been found to be more strongly associated with suicide
attempts when there is a co-occurring personality disorder.211
SCHIZOPHRENIA
Schizophrenia is a severe, chronic disorder characterized by disturbances in perception, thought, language,
and social function. The risk for suicide in individuals suffering from schizophrenia is particularly high in
the early stages of the illness (first 3–5 years of onset). A meta-analysis of more than 60 studies found that
almost 5 percent of schizophrenic patients will die by suicide during their lifetimes, usually near the onset
of the illness.26 Surviving the initial period of heightened risk results in a lesser, although still considerable,
risk of death by suicide.26
The greatest indicator of suicide risk among people with schizophrenia is active psychotic illness (e.g.,
delusions) combined with symptoms of depression. Greater insight into the psychotic illness itself, the
need for treatment, and the consequences of the disorder are strongly related to suicide risk.216 Increased
risk for suicide is also associated with higher levels of education and higher socioeconomic status. Alcohol
abuse has been reported in studies examining suicide attempts.
Newer nonpharmacological therapies, such as cognitive enhancement therapy, may have great potential for
improving the individual’s social and occupational functioning.217 Findings from a recent review suggest
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that an integrated psychosocial and pharmacological approach may be useful, and that treating depressive
symptoms in patients with schizophrenia is an important component of suicide risk reduction.87
Resources
Continuity of Care for Suicide Prevention and Research: Suicide Attempts and Suicide Deaths
Subsequent to Discharge From the Emergency Department or Psychiatry Inpatient Unit, 2010
SPRC
www.sprc.org/library/continuityofcare.pdf
This is a comprehensive report offering recommendations for the ongoing care of patients at risk for
suicide who have been treated in EDs and hospitals. It discusses 10 principles for improved continuity of
care and provides examples of seven integrated systems of care in the United States and Europe.
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developed the National Registry of Evidence-Based Programs and Practices (NREPP), which reviews
evidence of effectiveness for prevention programs on topics related to mental and substance use disorders,
including suicide. SAMHSA also sponsors several prevention campaigns.
Suicide Prevention Efforts for Individuals With Serious Mental Illness: Roles for the State Mental
Health Authority, 2008
National Association of State Mental Health Program Directors (NASMHPD)
www.sprc.org/library/SeriousMI.pdf
This report outlines the State Mental Health Authority’s (SMHA) leadership role in preventing suicide
among people with serious mental illness. It suggests ways in which SMHAs can increase collaboration,
raise awareness of the signs of suicide, and intervene to save lives.
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substance abuse may be out of control, they may be experiencing a number of life crises, and they may be
at peaks in depressive symptoms. In addition, mental disorders associated with suicidal behaviors, such as
mood disorders, PTSD, anxiety disorders, and some personality disorders, often co-occur among people
who have been treated for substance use disorders. Crises that are known to increase suicide risk, such as
relapse and treatment transitions, may occur during treatment. According to one study, compared with
the general population, individuals treated for alcohol abuse or dependence have a 10 times greater risk of
eventually dying by suicide.228 Among those who inject drugs, the risk is about 14 times greater than in the
general population.228
More is known about the factors that increase the risk of suicidal behaviors among this population than
about the factors that may be protective. SUDs share many risk factors with suicide: family history of
suicide or child abuse; history of mental disorders, particularly mood disorders; history of or family
history of addiction; impulsiveness; feelings of isolation; barriers to mental health and/or treatment;
relational, social, work, or financial losses; physical illness/chronic pain; access to lethal methods; and
prejudice associated with asking for help.
Perceiving that there are clear reasons to live is thought to be an important protective factor in this group.
Other protective factors may include: a child at home and/or childrearing responsibilities; an intact
marriage; a trusting relationship with a counselor, physician, or other service provider; employment;
religious attendance and/or belief in religious teachings against suicide; and an optimistic or positive
outlook. Sobriety can be a protective factor, along with attendance of mutual support group meetings.
Resources
National Institute on Alcohol Abuse and Alcoholism, NIH, HHS
www.niaaa.nih.gov
National Institute on Alcohol Abuse and Alcoholism (NIAAA) provides leadership in the national effort to
reduce alcohol-related problems. Alcohol is a significant risk factor for suicide, and the NIAAA publishes
studies on how alcohol use interacts with conditions such as depression and stress to contribute to suicide.
NIAAA also provides data on alcohol involvement in suicide.
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It has developed NREPP, which reviews evidence of effectiveness for prevention programs on topics
related to mental and substance use disorders, including suicide. SAMHSA also sponsors several
prevention campaigns.
Substance Abuse and Suicide Prevention: Evidence and Implications—A White Paper, 2008
Center for Substance Abuse Treatment (CSAT), SAMHSA, HHS
www.samhsa.gov/matrix2/508SuicidePreventionPaperFinal.pdf
This white paper provides an overview of the advances made over the past decade in substance abuse
prevention and treatment and suicide prevention. It addresses the epidemiology of suicide, provides an
overview of what we know about the impact of substance abuse on suicide risk, and explores suicide
prevention in the context of behavioral health promotion and illness prevention.
TIP 50: Addressing Suicidal Thoughts and Behaviors in Substance Abuse Treatment, 2009
www.kap.samhsa.gov/products/manuals/tips/pdf/TIP50.pdf
Video companion:
www.store.samhsa.gov/product/Addressing-Suicidal-Thoughts-and-Behaviors-in-Substance-Abuse
Treatment/VA10-TIP50
TIP 50 provides counselors with tools to use in treatment and agency administrators with ways to ensure
that suicide ideation is detected and addressed early and appropriately. TIP 50 also provides insights on
how various drugs used by clients might affect mood and addresses cultural and gender issues that could
influence behavior.
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behavior in that population, with 41 percent of adult respondents to the 2009 National Transgender
Discrimination Survey reporting lifetime suicide attempts.231
Most studies have found suicide attempt rates to be higher in gay/bisexual males than in lesbian/bisexual
women, which is the opposite of the gender pattern found in the general population. As in the overall
population, there is some evidence that the frequency of suicide attempts may decrease as LGB adolescents
move into adulthood,232 although patterns of suicide attempts across the lifespan of sexual minority people
have not been conclusively studied. Within LGB samples, especially high suicide attempt rates have been
reported among African American, Latino, Native American, and Asian American subgroups.233-235
Suicidal behaviors in LGBT populations appear to be related to “minority stress,”236 which stems from
the cultural and social prejudice attached to minority sexual orientation and gender identity. This stress
includes individual experiences of prejudice or discrimination, such as family rejection, harassment,
bullying, violence, and victimization. Increasingly recognized as an aspect of minority stress is
“institutional discrimination” resulting from laws and public policies that create inequities or omit LGBT
people from benefits and protections afforded others.231, 237-240 Individual and institutional discrimination
have been found to be associated with social isolation, low self-esteem, negative sexual/gender identity,
and depression, anxiety, and other mental disorders. These negative outcomes, rather than minority sexual
orientation or gender identity per se, appear to be the key risk factors for LGBT suicidal ideation and
behavior. An additional risk factor is contagion resulting from media coverage of LGBT suicide deaths that
presents suicidal behavior as a normal, rational response to anti-LGBT bullying or other experiences of
discrimination. Further research is needed to explore the pathways to suicidal behaviors for transgender
individuals, including the impact of prejudice and discrimination.
Factors that foster and promote resilience in LGBT people include family acceptance,239 connection
to caring others and a sense of safety,66 positive sexual/gender identity, and the availability of quality,
culturally appropriate mental health treatment.58 Strategies for preventing suicidal behaviors in LGBT
populations include: reducing sexual orientation and gender-related prejudice and associated stressors;
improving identification of depression, anxiety, substance abuse, and other mental disorders; increasing
availability and access to LGBT-affirming treatments and mental health services; reducing bullying and
other forms of victimization that contribute to vulnerability within families, schools, and workplaces;
enhancing factors that promote resilience, including family acceptance and school safety; changing
discriminatory laws and public policies; and reducing suicide contagion.
Collaboration between suicide prevention and LGBT organizations is needed to ensure the development of
culturally appropriate suicide prevention programs, services, and materials, and to facilitate access to care
for at-risk individuals. A promising example is the development of guidelines for media in talking about
suicide in LGBT populations241 created by a coalition of AFSP and several national LGBT organizations.
Another critical need is closing knowledge gaps through additional research and improved surveillance.
Efforts are underway to expand the inclusion of sexual orientation and gender identity measures in federal
health and mental health surveys, and to develop and test procedures for postmortem identification of
LGBT people in NVDRS.
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Resources
American Foundation for Suicide Prevention: LGBT Initiative
www.afsp.org/index.cfm?page_id=6FB9BA00-7E90-9BD4-C33BD398EAAE73C0
This initiative works on suicide prevention among the LGBT population in a number of ways, including
producing a conference, funding research grants, working to improve how the media covers anti-gay
bullying, helping its chapter volunteers bring understanding of suicide into their local LGBT communities,
and creating LGBT mental health educational resources and training tools.
Suicide Prevention Among LGBT Youth: A Workshop for Professionals Who Serve Youth
SPRC
www.sprc.org/training-institute/lgbt-youth-workshop
This is a free workshop kit to help staff in schools, youth-serving organizations, and suicide prevention
programs take action to reduce suicidal behavior among LGBT youth. It contains a Leader's Guide, sample
agenda, PowerPoint presentations, sample script, and handouts.
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For calendar year 2010, service members who were white and under the age of 25, junior enlisted (E1–E4),
or high school educated were at increased risk for suicide relative to comparison groups in the general
population.244 Service members most frequently used firearms as the means for suicide. Drug overdose
was the most frequent method for suicide attempts, and the misuse of prescription medication was more
frequent than illegal drugs. Most service members were not known to have communicated their potential
for self-harm with others prior to suicide or attempted suicide. The majority of service members who died
by suicide did not have a known history of a mental or substance use disorder. Finally, the overwhelming
majority of suicides occurred in a nondeployed setting, and more than half of those who died by suicide
did not have a history of deployment.
The Centers for Disease Control and Prevention (CDC) estimates that veterans account for approximately
20 percent of the deaths from suicide in America.245 There is controversy in the scientific literature about
whether suicide rates are higher among veterans than among other Americans after controlling for
sex, age, and minority status.246, 247 However, rates appear to be increased among two important groups:
veterans who have recently returned from service in Afghanistan and Iraq,248 and those who receive
health care services from the Veterans Health Administration (VHA),249 the health care system operated
by the U.S. Department of Veterans Affairs (VA). In the most recent years for which data are available,
suicide rates for male VHA patients were approximately 1.4 times greater than for other American men.
For female VHA patients, rates were approximately twice as high as among American women. Both
increases reflect the higher rates of medical and mental health conditions, disability, and other risk factors
for suicide that occur among VHA patients. In VHA, as in DoD, firearms represented the most common
means for suicide and overdoses represented the most common means for attempts.248 Approximately half
of all suicides in VHA occurred among patients known to have mental health conditions.250 An increase
in the suicide rate among returning veterans first appeared in 2006,248 and rates continue to be monitored
closely. The rates as observed echo the increase that occurred for the first few years after veterans returned
from service in Vietnam.251
Efforts to identify individuals at risk and to monitor the military and veteran populations as a whole are
currently in place in at DoD and VA. Mental health services have been enhanced in both departments, and
an array of suicide prevention programs have been implemented.
In DoD, the Deputy Assistant Secretary of Defense for Readiness (DASD(R)) leads a collaborative effort
across the Department to address suicide. The Final Report of the Department of Defense Task Force on
the Prevention of Suicide by Members of the Armed Forces251 has served as a catalyst for the Department
to review and assess all policies and programs that relate to suicide prevention. Based on the report
and action plans developed from it, a departmental implementation memorandum was signed by the
Under Secretary of Defense for Personnel and Readiness in September 2011 to guide the Department’s
ongoing efforts.
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Established in November 2011, the Defense Suicide Prevention Office (DSPO) is part of the DoD’s
Office of the Under Secretary of Defense for Personnel and Readiness. DSPO oversees all strategic
development, implementation, centralization, standardization, communication, and evaluation of DoD
suicide programs, policies, and surveillance activities. To reduce the impact of suicide on Service members
and their families, DSPO uses a range of approaches related to policy, research, communications, and
behavioral health. DSPO works closely with the Army, Navy, Air Force, Marine Corps, Coast Guard and
National Guard Bureau, as well as other governmental and nongovernmental agencies, to support Service
members and strengthen a resilient and ready force. DSPO strives to help foster a climate that encourages
Service members to seek help for their behavioral health issues.
VA’s current suicide prevention began with the approval of its Mental Health Strategic Plan in 2004.
Implementation of the plan led to an increase in core mental health staff on a national level, by 50 percent;
from about 14,000 in 2005 to about 21,000 by the end of 2010.248 Moreover, it led to developing the
Handbook on Uniform Mental Health Services in VA Medical Centers and Clinics,252 a policy document that
specifies requirements for services that must be available to all veterans with mental health conditions.
The VA suicide prevention program is based on the principle that prevention requires ready access to high-
quality mental health services within the health care system, supplemented by two additional components:
(1) public education and awareness activities promoting engagement for those who need help; and
(2) availability of specific services addressing the needs of those at high risk. Activities have included
creating a national office for suicide prevention, partnering with SAMHSA and its Lifeline program to
add a veterans’ call center to its national 800–273–TALK/8255 crisis line, funding suicide prevention
coordinators with support staff in each VA medical center, and initiating public information strategies
focused on promoting the use of the crisis line and of VA services for those in need.
Resources
Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury
www.dcoe.health.mil/SuicidePreventionWarriors.aspx
The Defense Centers of Excellence (DCoE) suicide prevention page includes information and campaign
materials to raise awareness and encourage help seeking and access to mental health services specific to
service branches of the military, families, and veterans. The DCoE sponsors the Real Warriors Campaign,
a multimedia portal with resources to promote resilience, facilitate recovery, and support reintegration of
returning service members, veterans, and their families.
National Guard/Reserve
www.ng.mil/features/suicide_prevention/default.aspx
The website for the National Guard’s suicide prevention program features a six-part film on resilience
among National Guard personnel. Other resources include a media gallery, a list of military and
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nonmilitary organizations with information on suicide, and news stories from National Guard leadership
and other branches of the military.
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Men in Midlife
While suicide rates have tended to decrease or remain stable for most age groups in the past two decades,
suicides in middle adulthood have increased.253, 254 Men in their adult years, from their early 20s through
their 50s, account for the bulk of suicides and the majority of years of life lost due to suicide.255 Yet there
has been little research on this demographic group, when compared with the number of studies conducted
with adolescents and older adults.
Although research exploring the recent surge in suicide in midlife is lacking, existing studies suggest that
the factors that may increase the risk for suicidal behaviors in this group are similar to those among other
age groups and in both sexes: mental illness that can be discerned from retrospective analyses (particularly
mood disorders), substance use disorders (particularly alcohol abuse), and access to lethal means.28, 80
However, these factors are likely to be exacerbated by other risk-related characteristics that occur more
frequently among males, such as the underreporting of mental health problems,256 a reluctance to seek
help,257 engagement in interpersonal violence,258 distress from economic hardship (e.g., unemployment),
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and dissolution of intimate relationships.259 More research is needed on the pathways and mechanisms that
contribute to suicide among midlife men, using developmental approaches that examine the occurrence
and timing of risk factors as they are expressed across the life course.
Very few systematic, large-scale efforts have addressed the prevention of suicide among men in midlife.
Although the AFSPP is an example,260, 261 it remains uncertain whether the lessons gleaned from this closed
system can be readily generalized to broader society. Prevention efforts are especially challenging for men
because they are less likely to show signs of depression, report suicidal ideation, or seek help or accept it
from others, and they often hide their suicide plans or preparations.
Several projects have focused on organizational-level components for early intervention and education. 260,
262, 263
Although studies in other countries point to the positive protective effects of means restriction,264,
265
no such programs have been successfully implemented in the United States. In terms of changing
individual-level trajectories toward suicide, early classroom interventions to enhance interpersonal skills
have been shown to reduce suicidal behaviors in early adulthood.266 Additional targets for intervention
include: preventing exposure to violence in early developmental periods, such as bullying/peer
victimization, childhood abuse, and domestic violence; enhancing academic engagement and reducing
school drop-out rates; mitigating or preventing persisting alcohol and drug misuse; and developing a
diverse array of community-based programs that engage men who otherwise would not seek care in
traditional health settings or in settings that provide care for mental or substance use disorders.254 Many of
these efforts now are being focused on veterans. However, few data are available at this time to identify a
particular evidence-based suicide prevention approach targeting men in midlife.
Resources
Although there are no resources specific to midlife adult suicide prevention, some interventions that focus
on workplace settings and gatekeeper training may be particularly relevant to reaching people in this
age range.
LivingWorks
www.livingworks.net
LivingWorks is an organization that delivers training in suicide prevention to various groups, including
the general public, caregivers, and professionals. Its training programs include ASIST, suicideTALK,
safeTALK, and suicideCARE.
QPR Institute
www.qprinstitute.com (Under “QPR for Organizations,” click on “Business.”)
The QPR Institute is centered on the “question, persuade, refer” strategy of suicide prevention training for
gatekeepers. The institute offers training and information materials tailored for a variety of organizations
and workplace settings, including businesses and corporations.
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Older Men
Older men, in particular those who are white, have disproportionately high rates of death by suicide. In
2009, the rate of death by suicide among older white men was 30.15 per 100,000—almost three times the
rate among the general population (11.77 per 100,000).1
Several factors can increase the risk for suicidal behaviors among older men, including the presence of
a mental disorder. Research suggests that older adults who die by suicide are more likely to meet criteria
for affective disorders (especially major depressive disorder) than younger adults.267 Other important risk
factors include physical illness and functional decline. Finally, an extensive body of literature indicates that
social disconnection increases risk for death by suicide in older men.267
Suicide in late life is qualitatively different than in younger adults. Older adults are more likely than
younger adults to die by suicide as a result of their first suicide attempt, in part because older adults are
more likely than younger adults to use highly lethal means to attempt suicide.267 Another important
difference is that older adults are less likely than younger adults either to have reported suicidal ideation
or to have sought mental health treatment prior to their deaths.268 Interestingly, however, research suggests
that most older adults who die by suicide are seen by primary care physicians in the last three months
of life.106
Although many suicide prevention efforts have targeted youth, older adults have also become a focus of
suicide prevention. Since 2001, many national and regional conferences have featured the topic, and many
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states have broadened or are in the process of broadening their suicide prevention strategies to include
older adults. Some states (e.g., Oregon and Maine) have separate plans for this age group. Mental health
parity for Medicare is now being phased in so that seniors in the United States will have the same copay
(20 percent) for mental health care as for physical health care.
Several interventions appear to offer significant promise for the prevention of suicide in late life. Most of
these interventions have focused on treating depressive symptoms.267 Because older men do not generally
seek mental health treatment, the most effective methods of treating mood disorders in older adults may
involve integrating evidence-based depression treatment into the work of primary care offices, social
service agencies, and aging services organizations that focus on addressing the needs of older adults.
Research has shown that collaborative care models that combine pharmacological and psychosocial
treatments for depressive symptoms may be particularly useful. Finally, there is evidence that interventions
that attempt to decrease social isolation and disconnection in late life may reduce risk for death
by suicide.267
Resources
It Takes a Community: Report on the Summit on Opportunities for Mental Health Promotion and
Suicide Prevention in Senior Living Communities, 2010
www.sprc.org/library_resources/items/it-takes-community-report-summit-opportunities-mental-health
promotion-and-s
This is a report of the October 2008 “It Takes a Community” summit to advance discussion and action to
improve the mental health and reduce the risk of suicide among residents of senior living communities
(SLCs). It provides a framework of whole population, at-risk population, and crisis response approaches
and includes findings from focus groups of SLC residents.
Late Life Suicide Prevention Toolkit: Life Saving Tools for Health Care Providers, 2006
Canadian Coalition for Seniors’ Mental Health
www.ccsmh.ca/en/projects/suicide.cfm
These training materials include an interactive, case-based DVD, the National Guidelines for Seniors'
Mental Health: The Assessment of Suicide Risk and Prevention of Suicide, a clinician pocket card, a
Facilitator's Guide, and a PowerPoint presentation.
Promoting Emotional Health and Preventing Suicide: A Toolkit for Senior Living Communities, 2011
SAMHSA
www.store.samhsa.gov/product/SMA10-4515
This toolkit contains resources to help staff in SLCs promote emotional health and prevent suicide among
their residents. The toolkit also provides resources to help residents become active participants in mental
health promotion and suicide prevention efforts.
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Charting the Future of Suicide Prevention: A 2010 Progress Review of the National Strategy and
Recommendations for the Decade Ahead, 2010
Education Development Center, Inc.
www.sprc.org/library/ChartingTheFuture_Fullbook.pdf
This report reviews developments in the field of suicide prevention in the 9 years following the publication
of the National Strategy for Suicide Prevention. It identifies the areas of most important progress, as well
as crucial areas that have gone relatively unaddressed. It also explores new issues and initiatives that have
emerged to claim attention or offer solutions.
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Australia
Living Is for Everyone (LIFE) Framework, 2007
Australian Government Department of Health and Ageing Commonwealth of Australia, Canberra
http://www.livingisforeveryone.com.au/Home.html
England
Consultation on Preventing Suicide in England: A Cross-Government Outcomes Strategy to Save
Lives, 2011
United Kingdom Department of Health
www.dh.gov.uk/en/Consultations/Liveconsultations/DH_128065
This document proposes a new suicide prevention strategy for England.
Ireland
Reach Out: Irish National Strategy for Action on Suicide Prevention 2005–2014
National Office for Suicide Prevention, Ireland
www.nosp.ie/reach_out.pdf
New Zealand
New Zealand Suicide Prevention Action Plan 2008–2012: The Evidence for Action
Ministry of Health, Wellington, New Zealand
www.spinz.org.nz/file/downloads/pdf/file_48.pdf
Norway
National Plan for Suicide Prevention 1994–1998, 1999
Norwegian Health Board
www.med.uio.no/klinmed/english/research/centres/nssf/articles/prevention/The_national_plan_for_
suicide_prevention_1994-1998.pdf
The Norwegian Plan for Suicide Prevention Follow-up Project 2000–2002: Building on Positive
Experiences, 2001
Norwegian Journal Suicidologi, no. 1
www.med.uio.no/klinmed/english/research/centres/nssf/articles/prevention/MehlumAndReinholdt.pdf
Scotland
Refreshing the National Strategy and Action Plan to Prevent Suicide in Scotland: Report of the
National Suicide Prevention Working Group, 2010
The Scottish Government
www.scotland.gov.uk/Publications/2010/10/26112102/0
This report describes the revised Scottish national strategy for suicide prevention.
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Jason Foundation
www.jasonfoundation.com
The Jason Foundation is an educational organization dedicated to the awareness and prevention of youth
suicide. It produces educational curricula and training programs for students, educators, youth workers,
and parents to help them identify and assist at-risk youth.
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Samaritans USA
www.samaritansusa.org
Samaritans USA provides services to those at risk for suicide, provides support for those who have
experienced a loss due to suicide, and educates caregivers and health providers. Crisis lines are the
cornerstone of Samaritans USA’s services. Samaritans USA also provides suicide prevention education to
the public and survivor support groups.
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SPRC coproduces the BPR for Suicide Prevention. SPRC also provides organizational support for the
National Action Alliance for Suicide Prevention.
Yellow Ribbon
www.yellowribbon.org
Yellow Ribbon is the producer of the adult gatekeeper training Be a Link!, and the youth program Ask
4 Help! Its services include providing technical assistance to states and communities and support to
survivors, including a list of survivor support groups across the United States.
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Appendix F: Glossary
Affected by suicide—All those who may feel the impact of suicidal behaviors, including those bereaved by
suicide, as well as community members and others.
Affective disorders—See mood disorders.
Anxiety disorder—An unpleasant feeling of fear or apprehension accompanied by increased physiological
arousal, defined according to clinically derived standard psychiatric diagnostic criteria.
Behavioral health—A state of mental/emotional being and/or choices and actions that affect wellness.
Behavioral health problems include substance abuse or misuse, alcohol and drug addiction, serious
psychological distress, suicide, and mental and substance use disorders. The term is also used to describe
the service systems encompassing the promotion of emotional health; the prevention of mental and
substance use disorders, substance use, and related problems; treatments and services for mental and
substance use disorders; and recovery support.
Bereaved by suicide—Family members, friends, and others affected by the suicide of a loved one (also
referred to as survivors of suicide loss).
Best practices—Activities or programs that are in keeping with the best available evidence regarding what
is effective.
Bipolar disorders—A mood disorder characterized by the presence or history of manic episodes usually,
but not necessarily, alternating with depressive episodes.
Bisexual—An adjective that refers to individuals whose sexual orientation or identity involves sexual,
physical, and/or romantic attraction to both men and women.
Boundaried system—A health care and community support system that provides behavioral and other
health care services to a defined population (e.g., Henry Ford Health System).
Community—A group of individuals residing in the same locality or sharing a common interest.
Comprehensive suicide prevention plans—Plans that use a multifaceted approach to addressing the
problem, for example, including interventions targeting biopsychosocial, social, and environmental
factors.
Comorbidity—The co-occurrence of two or more disorders, such as depressive disorder and substance
use disorder.
Complicated grief—Feelings of loss, following the death of a loved one, which are debilitating and do not
improve even after time passes. These painful emotions are so long lasting and severe that those who are
affected have trouble accepting the loss and moving on with their lives. Also referred to “traumatic grief ”
or “prolonged grief.”
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Healthy People 2020—The national prevention initiative that identifies opportunities to improve the
health of all Americans, with specific and measurable objectives to be met by 2020.
Indicated intervention—Intervention designed for individuals at high risk for a condition or disorder or
for those who have already exhibited the condition or disorder.
Intervention—A strategy or approach that is intended to prevent an outcome or to alter the course of
an existing condition (such as providing lithium for bipolar disorders, educating providers about suicide
prevention, or reducing access to lethal means among individuals with suicide risk).
Lesbian—An adjective that refers to women whose sexual orientation or identity involves sexual, physical,
and/or romantic attraction to other women.
Lesbian, gay, bisexual, or transgender—A blanket term that refers to those who identify as lesbian, gay,
bisexual, or transgender.
Ligature points—Elements in an environment that could be used to support a noose or other
strangulation devices (especially, for a suicide attempt).
Means—The instrument or object used to carry out a self-destructive act (e.g., chemicals, medications,
illicit drugs).
Means restriction—Techniques, policies, and procedures designed to reduce access or availability to
means and methods of deliberate self-harm.
Methods—Actions or techniques that result in an individual inflicting self-directed injurious behavior
(e.g., overdose).
Mental disorder—A diagnosable illness characterized by alterations in thinking, mood, or behavior
(or some combination thereof) associated with distress that significantly interferes with an individual’s
cognitive, emotional, or social abilities; often used interchangeably with mental illness.
Mental health—The capacity of individuals to interact with one another and the environment in ways
that promote subjective well-being, optimal development, and use of mental abilities (cognitive, affective,
and relational).
Mental health services—Health services that are specifically designed for the care and treatment of
persons with mental health problems, including mental illness. Mental health services include hospitals
and other 24-hour services, intensive community services, ambulatory or outpatient services, medical
management, case management, intensive psychosocial rehabilitation services, and other intensive
outreach approaches to the care of individuals with severe disorders.
Mental illness—See mental disorder.
Minority stress—The high levels of chronic stress experienced by members of minority populations
(including lesbian, gay, bisexual, or transgender populations) as a result of the prejudice and
discrimination they experience from the dominant group in society.
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Mood disorders—A term used to describe all mental disorders that are characterized by a prominent or
persistent mood disturbance; disturbances can be in the direction of elevated expansive emotional states
or, if in the opposite direction, depressed emotional states. These disorders include depressive disorders,
bipolar disorders, mood disorders because of a medical condition, and substance-induced mood disorders.
Morbidity—The relative frequency of illness or injury, or the illness or injury rate, in a community
or population.
(see Centers for Disease Control and Prevention surveillance definitions box at the end of this appendix).
Objective—A specific and measurable statement that clearly identifies what is to be achieved in a plan;
it narrows a goal by specifying who, what, when, and where or clarifies by how much, how many, or
how often.
Outcome—A measurable change in the health of an individual or group of individuals that is attributable
to an intervention.
Personality disorders—A class of mental disorders characterized by deeply ingrained, often inflexible,
maladaptive patterns of relating, perceiving, and thinking of sufficient severity to cause either impairment
in functioning or distress.
Postvention—Response to and care for individuals affected in the aftermath of a suicide attempt or
suicide death.
Prevention—A strategy or approach that reduces the likelihood of risk of onset or delays the onset of
adverse health problems, or reduces the harm resulting from conditions or behaviors.
Protective factors—Factors that make it less likely that individuals will develop a disorder.
Protective factors may encompass biological, psychological, or social factors in the individual, family,
and environment.
Psychiatry—The medical science that deals with the origin, diagnosis, prevention, and treatment of
mental disorders.
Psychology—The science concerned with the individual behavior of humans, including mental and
Rate—The number per unit of the population with a particular characteristic, for a given unit of time.
Resilience—Capacities within a person that promote positive outcomes, such as mental health and well
being, and provide protection from factors that might otherwise place that person at risk for adverse
health outcomes.
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Risk factors—Factors that make it more likely that individuals will develop a disorder. Risk factors may
encompass biological, psychological, or social factors in the individual, family, and environment.
Root cause analysis—Root cause analysis (RCA) is a step-by-step method that leads to the discovery
of a fault’s first or root cause. RCA uses a systematic approach to identify the progression of actions and
consequences that led to an undesired event. In the context of suicide prevention, an RCA investigation
means tracing the cause and effect trail from a suicide attempt or death back to the root cause.
Safety plan—Written list of warning signs, coping responses, and support sources that an individual may
use to avert or manage a suicide crisis.
Screening—Administration of an assessment tool to identify persons in need of more indepth evaluation
or treatment.
Screening tools—Instruments and techniques (e.g., questionnaires, check lists, self-assessment forms)
used to evaluate individuals for increased risk of certain health problems.
Selective intervention—Intervention targeted to subgroups of the population whose risk of developing a
health problem is significantly higher than average.
Self-directed violence (same as self-injurious behavior)—Behavior that is self-directed and deliberately
results in injury or the potential for injury to oneself. Self-directed violence can be categorized as either
nonsuicidal or suicidal.
Self-inflicted injuries—Injuries caused by suicidal and nonsuicidal behaviors such as self-mutilation.
Sexual orientation—An individual’s sexual, physical, and/or romantic attraction to men, women, both,
or neither.
Social support—Assistance that may include companionship, emotional backing, cognitive guidance,
material aid, and special services.
Specialty treatment centers (e.g., mental health, substance abuse)—Health facilities where the personnel
and resources focus on specific aspects of psychological or behavioral well-being.
Stakeholders—Entities including organizations, groups, and individuals that are affected by and
contribute to decisions, consultations, and policies.
Substance use disorder—A maladaptive pattern of substance use manifested by recurrent and significant
adverse consequences related to repeated use; includes maladaptive use of legal substances such as alcohol;
prescription drugs such as analgesics, sedatives, tranquilizers, and stimulants; and illicit drugs such as
marijuana, cocaine, inhalants, hallucinogens, and heroin.
Suicidal behaviors—Behaviors related to suicide, including preparatory acts, as well as suicide attempts
and deaths.
Suicidal self-directed violence—Behavior that is self-directed and deliberately results in injury or the
potential for injury to oneself. There is evidence, whether implicit or explicit, of suicidal intent.
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Other suicidal behavior Acts or preparation toward making a suicide attempt, but before
including preparatory acts potential for harm has begun. This can include anything beyond
a verbalization or thought, such as assembling a method (e.g.,
collecting pills) or preparing for one’s death by suicide (e.g., writing a
suicide note, giving things away).
Self-directed violence Behavior that is self-directed and deliberately results in injury or the
potential for injury to oneself.
Suicidal intent There is evidence (explicit and/or implicit) that at the time of injury the
individual intended to kill self or wished to die and that the individual
understood the probable consequences of his or her actions.
Suicidal self-directed Behavior that is self-directed and deliberately results in injury or the
violence potential for injury to oneself. There is evidence, whether implicit or
explicit, of suicidal intent.
Suicide Death caused by self-directed injurious behavior with any intent to die
as a result of the behavior.
Suicide attempt A nonfatal, self-directed, potentially injurious behavior with any intent
to die as a result of the behavior. A suicide attempt may or may not
result in injury.
SOURCE: Crosby A, Ortega L, Melanson C. Self-directed violence surveillance: Uniform definitions and recommended data el
ements, Version 1.0. Atlanta, GA: Centers for Disease Control and Prevention, National Center for Injury Prevention and Control;
2011. Available at www.cdc.gov/ViolencePrevention/pub/selfdirected_violence.html.
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those funds;
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Administration on Aging
Mission: To develop a comprehensive, coordinated, and cost-effective system of home and community-
based services that helps elderly individuals maintain their health and independence in their homes
and communities. To achieve this mission, the Administration on Aging (AoA) works with states and
communities to enhance the availability of effective and coordinated services that are responsive to the
needs and preferences of older persons, persons with disabilities, and their family caregivers.
AoA was established in 1965 with the passage of the Older Americans Act and is charged with advancing
the concerns and interests of older people, persons with disabilities, and their family caregivers. To
accomplish this vision, AoA administers a combination of competitive and formula grants that support
the development, delivery, and evaluation of supportive services through the Aging Network, which
consists of 56 State Units on Aging, 629 Area Agencies on Aging, 256 Tribal and Native organizations,
20,000 service providers, and thousands of volunteers. By leveraging public and private resources and
partnerships, the Aging Network delivers streamlined access to a robust menu of supports, including
long-term care services, nutrition programs, preventive health services, family caregiver programs, care
transitions interventions, and supports that prevent elder abuse and promote elder rights.
Physical illness, emotional issues, and functional impairment are common risk factors for suicide among
older adults. Through AoA’s evidence-based health, dementia, and wellness programs, the Aging Network
is developing a national system of effective programs, including depression care and suicide prevention
programs, that help older adults, persons with disabilities, and their family caregivers maintain their health
and independence. AoA envisions the continuation of a vibrant, integrated system that provides access to
person-centered supportive services that promote physical and emotional well-being. AoA has recently
become a part of the Administration for Community Living.
For additional information:
Administration on Aging
Web address: www.aoa.gov
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need to protect their health—through health promotion, prevention of disease, injury and disability, and
The Centers for Disease Control and Prevention (CDC), a part of HHS, is the primary federal agency for
conducting and supporting public health activities in the U.S. Through its centers, institutes, and offices,
CDC works with partners throughout the nation and the world to monitor health, detect and investigate
health problems, develop and advocate sound public health policies, implement prevention strategies,
promote healthy behaviors, foster safe and healthful environments, and provide leadership and training.
CDC suicide prevention activities include efforts in the National Center for Health Statistics, National
Center for Chronic Disease Prevention and Health Promotion, and National Center for Injury Prevention
and Control. CDC maintains national data on suicides, conducts the Youth Risk Behavior Survey, and
publishes reports on self-directed injury at all levels. Additional examples of CDC activities include
promoting collaborations in specific communities for suicide prevention and conducting research on
suicidal behavior and program evaluation.
For additional information:
Centers for Disease Control and Prevention
Web address: www.cdc.gov
National Injury Center’s Division of Violence Prevention
Web address: www.cdc.gov/violenceprevention
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Acknowledgments
National Action Alliance for Suicide Prevention Executive Committee (EXCOM)
The Honorable Secretary John M. McHugh The Honorable Senator Gordon H. Smith
Secretary of the Army President and CEO
Public Sector Co-Chair National Association of Broadcasters
Private Sector Co-Chair
Full Members
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Former Members
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Ex-Officio Members
Regina Benjamin, MD, MBA Howard K. Koh, MD, MPH Mary Wakefield, PhD, RN
Surgeon General of the United States Assistant Secretary for Health Administrator
Office of the Surgeon General U.S. Department of Health and Health Resources and
U.S. Department of Health and Human Services Services Administration
Human Services U.S. Department of Health and
Thomas Insel, MD
Human Services
Thomas Frieden, MD, MPH Director
Director National Institute of Mental Health
Centers for Disease Control National Institutes of Health
and Prevention U.S. Department of Health and
U.S. Department of Health and Human Services
Human Services
Yvette Roubideaux, MD, MPH
Kathy Greenlee, JD Director
Assistant Secretary for Aging Indian Health Service
Administration on Aging U.S. Department of Health and
U.S. Department of Health and Human Services
Human Services
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Other Contributors
Writers of Appendix D: Groups With Increased Suicide Risk
American Indians/Alaska Natives: Petrice Post, MA; Ellyson Stout, MS; and Cortney Yarholar, LMSW
Individuals Bereaved by Suicide: John (Jack) Jordan, PhD
Individuals in Justice and Child Welfare Settings: Lindsay Hayes, MS; Jason H. Padgett, MPA, MSM; and
Katherine Wootten Deal, MPH
Individuals Who Engage in Non-Suicidal Self-Injury: Morton Silverman, MD
Individuals Who Have Attempted Suicide: Eduardo Vega, MA
Individuals with Medical Conditions: Morton Silverman, MD
Individuals with Mental and Substance Use Disorders: Morton Silverman, MD; and Michael Botticelli, MEd
Lesbian, Gay, Bisexual, and Transgender (LGBT) Populations: Ann Haas, PhD; Andrew Lane; and Effie
Malley, MPA
Members of the Armed Forces and Veterans: Leonard Litton, III, Colonel (Ret.); Ira Katz, MD, PhD; and Jan
Kemp, RN, PhD
Men in Midlife: John R. Blosnich, PhD, MPH; and Eric Caine, MD
Older Men: Yeates Conwell, MD; and Alisa O’Riley, PhD
Breshears, PhD; Heidi Bryan; Eric Caine, MD; Donna Carender, MS; Yeates Conwell, MD; Lisa Colpe, PhD;
Katherine Wootten Deal, MPH; Mark Evans, PhD; Barri Faucett, MA; Amy Fiske, PhD, CBSM; Ann Haas, PhD;
Katherine Hempstead, PhD; Jeff Inman, MS; Sean Joe, PhD; Ira Katz, MD, PhD; Jan Kemp, PhD, RN; Marilyn
Koenig; Lesley Levin, LCSW; Gary McConahay, PhD; Richard McKeon, PhD; Doreen S. Marshall, PhD, LPC;
Elaine de Mello, LCSW; Matthew Miller, MD, MPH, ScD; Jason H. Padgett, MPA, MSM; Rich Paul, MSW; Richard
Ramsay, MSW, RSW; Jerry Reed, PhD, MSW; Dan Reidenberg, PsyD, FAPA; Scott Ridgway, MS; Karl Rosston, LCSW;
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Garrett Lee Smith Memorial Act/SAMHSA State/Tribal Grantee Meeting (February 17, 2011)
Behavioral Health Subcommittee at the Legislative and Policy Conference of the National Association of
County Behavioral Health and Developmental Disability Directors, held in association with the spring meeting
Department of Defense, Department of Veterans Affairs Suicide Prevention Conference (March 16, 2011)
Other Reviewers
Ella Arensman, PhD, MSc; Deborah, Azrael, PhD; Cathy Barber, MPA; David W. Fleming, MD; David Grossman,
MD, MPH; Jeff Levi, PhD; Lars Mehlum MD, PhD; Matthew Miller, ScD; Paul Quinnett, PhD
Staff Support
Maryland Arciaga; Emily Barocas; Colleen Carr, MPH; Renata Casiel; Katherine Wootten Deal, MPH; Ingrid Donato;
Magdala Labre, PhD, MPH; Liz Lebreton, MPH; David Litts, OD; Liliya Melnyk; Chris Miara, MS; Jason H. Padgett,
MPA, MSM; Laurie Rosenblum, MPH; and Xan Young, MPH
We also would like to acknowledge the important contributions of the numerous individuals
who provided input and public comments throughout the revision process.
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References
1. Centers for Disease Control and Prevention. Fatal injury data, 2009. Web-based Injury Statistics
Query and Reporting System. Available at www.cdc.gov/injury/wisqars/fatal.html. Accessed
January 12, 2012.
2. Mcintosh JL. U.S.A. suicide: 2009 official final data. Washington, DC: American Association
of Suicidology; 2012. Available at www.suicidology.org/c/document_library/get_
file?folderId=228&name=DLFE-494.pdf. Accessed May 23, 2012.
3. Substance Abuse and Mental Health Services Administration. Utilization of mental health services
by adults with suicidal thoughts and behavior. (National Survey on Drug Use and Health. The
NSDUH Report.) Rockville, MD: Author; 2011.
4. Centers for Disease Control and Prevention. Youth risk behavior surveillance—United States,
2011. MMWR. 2012;61(4):1-162.
5. U.S. Public Health Service. The Surgeon General’s call to action to prevent suicide. Washington, DC:
Author; 1999.
6. U.S. Department of Health and Human Services. National strategy for suicide prevention: goals and
objectives for action. Rockville, MD: Author; 2001.
7. Suicide Prevention Resource Center (SPRC) and Suicide Prevention Action Network USA (SPAN
USA). Charting the future of suicide prevention: a 2010 progress review of the National Strategy and
recommendations for the decade ahead. David Litts, ed., Newton, MA: Education Development
Center, Inc.; 2010.
8. Harris EC, Barraclough B. Suicide as an outcome for mental disorders. A meta-analysis. Br J
Psychiatry. 1997;170:205-228.
9. Goldsmith S, Pellmar T, Kleinman A, Bunney W, eds. Reducing suicide: a national imperative.
Washington, D.C.: Institute of Medicine, The National Academies Press; 2002.
10. Suicide Prevention Resource Center, Rodgers P. Understanding risk and protective factors for
suicide: a primer for preventing suicide. Available at www.sprc.org/library_resources/items/
understanding-risk-and-protective-factors-suicide-primer-preventing-suicide. Accessed May
12, 2012.
11. Fowler JC. Suicide risk assessment in clinical practice: pragmatic guidelines for imperfect
assessments. Psychotherapy. 2012;49(1):81-90.
12. Sisask M, Varnik A. Media roles in suicide prevention: a systematic review. Int J Environ Res Public
Health. 2012;9(1):123-138.
13. Pompili M, Serafini G, Innamorati M, et al. Suicidal behavior and alcohol abuse. Int J Environ Res
Public Health. 2010;7(4):1392-1431.
PAGE 164
2012 NATIONAL STRATEGY FOR SUICIDE PREVENTION
14. Swahn MH, Ali B, Bossarte RM, et al. Self-harm and suicide attempts among high-risk, urban
youth in the U.S.: shared and unique risk and protective factors. Int J Environ Res Public
Health. 2012;9(1):178-191.
15. Lubell KM, Vetter JB. Suicide and youth violence prevention: the promise of an integrated
approach. Aggress Violent Behav. 2006;11(2):167-175.
16. Knox KL, Litts DA, Talcott GW, Feig JC, Caine ED. Risk of suicide and related adverse
outcomes after exposure to a suicide prevention programme in the US Air Force: cohort study.
BMJ. 2003;327(7428):1376.
17. Centers for Disease Control and Prevention. Fatal injury data, 2008. Web-based Injury Statistics
Query and Reporting System. Available at www.cdc.gov/injury/wisqars. Accessed January
12, 2012.
18. Crosby AE, Han B, Ortega LA, Parks SE, Gfroerer J. Suicidal thoughts and behaviors among adults
aged ≥18 years—United States, 2008–2009. MMWR Surveill Summ. 2011;60(SS13):1-22.
19. Centers for Disease Control and Prevention. National Violent Death Reporting System. Available
at www.cdc.gov/violenceprevention/nvdrs/index.html. Accessed January 17, 2012.
20. Centers for Disease Control and Prevention. WISQARS™—Your source for U.S. injury statistics.
Available at www.cdc.gov/injury/wisqars/facts.html. Accessed January 17, 2012.
21. Borowsky IW, Resnick MD, Ireland M, Blum RW. Suicide attempts among American Indian and
Alaska Native youth: risk and protective factors. Arch Pediatr Adolesc Med. 1999;153(6):573-580.
22. Frank ML, Lester D. Self-destructive behaviors in American Indian and Alaska Native high school
youth. Am Indian Alsk Native Ment Health Res. 2002;10(3):24-32.
23. Freedenthal S, Stiffman AR. Suicidal behavior in urban American Indian adolescents:
a comparison with reservation youth in a southwestern state. Suicide Life Threat
Behav. 2004;34(2):160-171.
24. Valtonen H, Suominen K, Mantere O, Leppamak iS, Arvilommi P, Isometsa ET. Suicidal ideation
and attempts in bipolar I and II disorders. J Clin Psychiatry. 2005;66(11):1456-1462.
25. Tondo L, Isacsson G, Baldessarini R. Suicidal behaviour in bipolar disorders: risk and prevention.
CNS Drugs. 2003;17(7):491-511.
26. Palmer BA, Pankratz VS, Bostwick JM. The lifetime risk of suicide in schizophrenia: a
reexamination. Arch Gen Psychiatry. 2005;62(3):247-253.
27. Karch DL, Logan J, Patel N. Surveillance for violent deaths—National Violent Death Reporting
System, 16 states, 2008. MMWR Surveill Summ. 2011;60(SS10):1-49.
28. Tondo L, Baldessarini RJ, Hennen J, et al. Suicide attempts in major affective disorder patients with
comorbid substance use disorders. J Clin Psychiatry. 1999;60 Suppl 2:63-69.
PAGE 165
2012 NATIONAL STRATEGY FOR SUICIDE PREVENTION
29. Berman AL, Pompili M, eds. Medical conditions associated with suicide risk. Washington, DC:
American Association of Suicidology; 2011.
30. Lofthouse N, Yager-Schweller J. Nonsuicidal self-injury and suicide risk among adolescents. Curr
Opin Pediatr. 2009;21(5):641-645.
31. Hawton K, Harriss L, Zahl D. Deaths from all causes in a long-term follow-up study of 11,583
deliberate self-harm patients. Psychol Med. 2006;36(3):397-405.
32. World Health Organization and International Association for Suicide Prevention. Preventing
suicide in jails and prisons. Geneva, Switzerland: WHO Document Production Services; 2007.
33. Hayes L. Suicide prevention in correctional facilities. In: Scott C, Gerbasi J, eds. Handbook of
correctional mental health. Washington, DC: American Psychiatric Publishing; 2005:69–88.
34. Mumola C, Noonan M. Deaths in custody statistical tables. Washington, DC: U.S. Department of
Justice, Office of Justice Programs, Bureau of Justice Statistics; 2008.
35. Mumola C. Suicide and homicide in state prisons and local jails. (Bureau of Justice Statistics Special
Report). Washington, DC: U.S. Department of Justice, Office of Justice Programs, Bureau of Justice
Statistics; 2005.
36. Leslie LK, James S, Monn A, Kauten MC, Zhang J, Aarons G. Health-risk behaviors in young
adolescents in the child welfare system. J Adolesc Health. 2010;47(1):26-34.
37. Pilowsky DJ, Wu LT. Psychiatric symptoms and substance use disorders in a nationally
representative sample of American adolescents involved with foster care. J Adolesc
Health. 2006;38(4):351-358.
38. Marshal MP, Dietz LJ, Friedman MS, et al. Suicidality and depression disparities between sexual
minority and heterosexual youth: a meta-analytic review. J Adolesc Health. 2011;49(2):115-123.
39. Jordan J, Mc&Intosh JL, eds. Grief after suicide: Understanding the consequences and caring for the
survivors. New York: Routledge; 2011.
40. Brown GK, Ten Have T, Henriques GR, Xie SX, Hollander JE, Beck AT. Cognitive therapy for the
prevention of suicide attempts: a randomized controlled trial. JAMA. 2005;294(5):563-570.
41. Linehan MM, Comtois KA, Murray AM, et al. Two-year randomized controlled trial and follow-
up of dialectical behavior therapy vs therapy by experts for suicidal behaviors and borderline
personality disorder. Arch Gen Psychiatry. 2006;63(7):757-766.
42. Knox KL, Kemp J, McKeon R, Katz IR. Implementation and early utilization of a suicide hotline
for veterans. Am J Public Health. 2012;102 Suppl 1:S29-S32.
43. Knesper
DJ. Continuity of care for suicide prevention and research: suicide attempts and suicide
deaths subsequent to discharge from the emergency department or psychiatry inpatient unit. Newton,
MA: Suicide Prevention Resource Center; 2010.
PAGE 166
2012 NATIONAL STRATEGY FOR SUICIDE PREVENTION
44. Wasserman D, Rihmer Z, Rujescu D, et al. The European Psychiatric Association (EPA) guidance
on suicide treatment and prevention. Eur Psychiatry. 2012;27(2):129-141.
45. Centers for Disease Control and Prevention. Strategic direction for the prevention of suicidal
behavior: promoting individual, family, and community connectedness to prevent suicidal
behavior. Available at www.cdc.gov/ViolencePrevention/pdf/Suicide_Strategic_Direction_Full_
Version-a.pdf. Accessed May 12, 2012.
46. Suicide Prevention Resource Center. Best practices registry (BPR) for suicide prevention. Available
at www2.sprc.org/bpr/index. Accessed January 26, 2012.
47. National Prevention Council. National prevention strategy. Washington, DC: U.S. Department of
Health and Human Services, Office of the Surgeon General; 2011. Available at www.healthcare.
gov/prevention/nphpphc/strategy. Accessed April 20, 2012.
48. U.S. Department of Health and Human Services, Office of Minority Health. National standards
for culturally and linguistically appropriate services in health care: final report. Washington, DC:
Author; March 2001. Available at www.minorityhealth.hhs.gov/assets/pdf/checked/finalreport.pdf.
Accessed April 20, 2012.
49. Coffey CE. Building a system of perfect depression care in behavioral health. Jt Comm J Qual
Patient Saf. 2007;33(4):193–199.
50. While D, Bickley H, Roscoe A, et al. Implementation of mental health service recommendations
in England and Wales and suicide rates, 1997-2006: a cross-sectional and before-and-after
observational study. Lancet. 2012;379(9820):1005-1012.
51. Kellam SG, Mackenzie AC, Brown CH, et al. The good behavior game and the future of prevention
and treatment. Addict Sci Clin Pract. 2011;6(1):73-84.
52. The Safe States Alliance. Preventing violence: roles for public health agencies. Atlanta, GA:
Author; 2011.
53. United
Nations. Prevention of suicide: guidelines for the formulation and implementation of national
strategies. New York: Author; 1996.
54. Centers for Medicare & Medicaid Services, U.S. Department of Health and Human Services.
Medicare and Medicaid programs: electronic health record incentive program–stage 2. Available at
www.regulations.gov/#!documentDetail;D=CMS-2012-0022-0001. Accessed April 16, 2012.
55. Noar SM, Palmgreen P, Chabot M, Dobransky N, Zimmerman RS. A 10-year systematic
review of HIV/AIDS mass communication campaigns: have we made progress? J Health
Commun. 2009;14(1):15-42.
56. National Institutes of Health. Making health communication programs work. Washington, DC:
National Cancer Institute; 2001. Available at www.cancer.gov/pinkbook. Accessed April 18, 2012.
PAGE 167
2012 NATIONAL STRATEGY FOR SUICIDE PREVENTION
57. Centers for Disease Control and Prevention. Gateway to health communication & social
marketing practice. Available at www.cdc.gov/healthcommunication. Accessed April 18, 2012.
58. Haas AP, Eliason M, Mays VM, et al. Suicide and suicide risk in lesbian, gay, bisexual, and
transgender populations: review and recommendations. J Homosex. 2011;58(1):10-51.
59. Fox S. Mobile health 2010. Washington, DC: Pew Research Center’s Internet & American Life
Project; October 19, 2010. Available at www.pewinternet.org/Reports/2010/Mobile-Health-2010.
aspx. Accessed May 14, 2012.
60. Luxton DD, June JD, Kinn JT. Technology-based suicide prevention: current applications and
future directions. Telemed J E Health. 2011;17(1):50-54.
61. U.S. Department of Veterans Affairs. Veterans crisis line website. Available at
www.veteranscrisisline.net. Accessed April 17, 2012.
62. Centers for Disease Control and Prevention. The health communicator’s social media toolkit.
Atlanta, GA; July 2011. Available at www.cdc.gov/healthcommunication/ToolsTemplates/
SocialMediaToolkit_BM.pdf. Accessed April 18, 2012.
63. Centers for Disease Control and Prevention. CDC’s guide to writing for social media.
Atlanta, GA; April 2012. Available at http://www.cdc.gov/socialmedia/Tools/guidelines/pdf/
GuidetoWritingforSocialMedia.pdf. Accessed May 14, 2012.
64. May PA, Serna P, Hurt L, Debruyn LM. Outcome evaluation of a public health approach to suicide
prevention in an American Indian tribal nation. Am J Public Health. 2005;95(7):1238-1244.
65. Motto JA, Bostrom AG. A randomized controlled trial of postcrisis suicide prevention. Psychiatr
Serv. 2001;52(6):828-833.
66. Eisenberg ME, Resnick MD. Suicidality among gay, lesbian and bisexual youth: the role of
protective factors. J Adolesc Health. 2006;39(5):662-668.
67. O’Carroll PW, Mercy JA, Steward JA. CDC recommendations for a community plan
for the prevention and containment of suicide clusters. MMWR Morb Mortal Wkly
Rep. 1988;37(S-6):1-12.
68. Recommendations for reporting on suicide. Available at www.reportingonsuicide.org. Accessed
November 21, 2011.
69. Substance Abuse and Mental Health Services Administration (SAMHSA), Entertainment
Industries Council (EIC). Picture this: depression and suicide prevention. Washington, DC:
Substance Abuse and Mental Health Services Administration; 2009.
70. O’Connell M, Boat T, Warner K, eds. Preventing mental, emotional, and behavioral disorders among
young people: progress and possibilities. Washington, DC: National Research Council and Institute
of Medicine, The National Academies Press; 2009.
PAGE 168
2012 NATIONAL STRATEGY FOR SUICIDE PREVENTION
71. Rihmer Z. Suicide risk in mood disorders. Curr Opin Psychiatry. 2007;20(1):17-22.
72. Mann JJ, Apter A, Bertolote J, et al. Suicide prevention strategies: a systematic review.
JAMA. 2005;294(16):2064-2074.
73. Van der Feltz-Cornelis CM, Sarchiapone M, Postuvan V, et al. Best practice elements of multilevel
suicide prevention strategies. Crisis. 2011:1-15.
74. Brent DA. Firearms and suicide. Ann N Y Acad Sci. 2001;932:225-239; discussion; 239-240.
75. Brent DA, Bridge J. Firearms availability and suicide: evidence, interventions, and future
directions. Ame Behav Sci. 2003;46(9):1192-1210.
76. Cummings P, Koepsell TD. Does owning a firearm increase or decrease the risk of death?
JAMA. 1998;280(5):471-473.
77. Miller M, Hemenway D. Gun prevalence and the risk of suicide: A review. Harvard Health Policy
Rev. 2001;2:29-37.
78. Ilgen MA, Zivin K, McCammon RJ, Valenstein M. Mental illness, previous suicidality, and access
to guns in the United States. Psychiatr Serv. 2008;59(2):198-200.
79. Betz ME, Barber C, Miller M. Suicidal behavior and firearm access: results from the second injury
control and risk survey. Suicide Life Threat Behav. 2011;41(4):384-391.
80. Miller M, Barber C, Azrael D, Hemenway D, Molnar BE. Recent psychopathology, suicidal
thoughts and suicide attempts in households with and without firearms: findings from the
National Comorbidity Study Replication. Inj Prev. 2009;15(3):183-187.
81. Kreitman N. The coal gas story. United Kingdom suicide rates, 1960-71. Br J Prev Soc
Med. 1976;30(2):86-93.
82. Gunnell D, Fernando R, Hewagama M, Priyangika WD, Konradsen F, Eddleston M. The impact of
pesticide regulations on suicide in Sri Lanka. Int J Epidemiol. 2007;36(6):1235-1242.
83. Suicide Prevention Resource Center (SPRC) and Suicide Prevention Action Network USA (SPAN
USA). Charting the future of suicide prevention: a 2010 progress review of the National Strategy and
recommendations for the decade ahead. David Litts, ed., Newton, MA: Education Development
Center, Inc.; August 2010.
84. McDowell AK, Lineberry TW, Bostwick JM. Practical suicide-risk management for the busy
primary care physician. Mayo Clin Proc. 2011;86(8):792-800.
85. Alexopoulos GS, Reynolds CF, 3rd, Bruce ML, et al. Reducing suicidal ideation and
depression in older primary care patients: 24-month outcomes of the PROSPECT study. Am J
Psychiatry. 2009;166(8):882-890.
86. Kasckow J, Felmet K, Zisook S. Managing suicide risk in patients with schizophrenia. CNS
Drugs. 2011;25(2):129-143.
PAGE 169
2012 NATIONAL STRATEGY FOR SUICIDE PREVENTION
PAGE 170
2012 NATIONAL STRATEGY FOR SUICIDE PREVENTION
99. Baraff LJ, Janowicz N, Asarnow JR. Survey of California emergency departments about
practices for management of suicidal patients and resources available for their care. Ann Emerg
Med. 2006;48(4):452-458.
100. Olfson M, Marcus SC, Bridge JA. Emergency treatment of deliberate self-harm. Arch Gen
Psychiatry. 2012;69(1):80-88.
101. Asarnow J, Baraff L, Berk M, et al. An emergency department intervention for linking pediatric
suicidal patients to follow-up mental health treatment. Psych Serv. 2011;62(11):1303-1309.
102. Currier GW, Fisher SG, Caine ED. Mobile crisis team intervention to enhance linkage of
discharged suicidal emergency department patients to outpatient psychiatric services: a
randomized controlled trial. Acad Emerg Med. 2010;17(1):36-43.
103. Carter GL, Clover K, Whyte IM, Dawson AH, D’Este C. Postcards from the EDge project:
randomised controlled trial of an intervention using postcards to reduce repetition of hospital
treated deliberate self poisoning. BMJ. 2005;331(7520):805.
104. Department of Veterans’ Services. Statewide Advocacy for Veterans’ Empowerment (SAVE).
Available at www.mass.gov/veterans/health-and-well-being/counseling/suicide-prevention-only/
save.html. Accessed May 15, 2012.
105. Larkin GL, Beautrais AL. Emergency departments are underutilized sites for suicide prevention.
Crisis. 2010;31(1):1-6.
106. Luoma JB, Martin CE, Pearson JL. Contact with mental health and primary care providers before
suicide: a review of the evidence. Am J Psychiatry. 2002;159(6):909-916.
107. American Association of Suicidology. AAS recommendations for inpatient and residential
patients known to be at elevated risk for suicide. Washington, DC: American Association of
Suicidology; 2005.
108. Crosby A, Ortega L, Melanson C. Self-directed violence surveillance: uniform definitions and
recommended data elements, Version 1.0. Atlanta, GA: Centers for Disease Control and Prevention,
National Center for Injury Prevention and Control; 2011.
109. National Center for Injury Prevention and Control. Recommended actions to improve external
cause-of-injury coding in state-based hospital discharge and emergency department data systems.
Atlanta, GA: U.S. Department of Health and Human Services, Centers for Disease Control and
Prevention; December 2009.
110. Shekelle P, Bagley S, Munjas B. Strategies for suicide prevention in veterans. Washington, DC; 2009.
111. Resnik HLP, Hathorne BC. Suicide prevention in the 70s. Rockville, MD: National Institute of
Mental Health; 1973.
PAGE 171
2012 NATIONAL STRATEGY FOR SUICIDE PREVENTION
112. Alcohol, Drug Abuse, and Mental Health Administration. Report of the Secretary’s Task Force on
Youth Suicide: Vols. 1-4. Washington, DC: U.S. Government Printing Office (DHHS Publication
No. ADM 89-1624); 1989.
113. New Freedom Commission on Mental Health. Achieving the promise: transforming mental health
care in America. Final report. MD: DHHS Pub. No. SMA-03-3832. Rockville; 2003.
114. Kalafat J, Gould MS, Munfakh JL, Kleinman M. An evaluation of crisis hotline outcomes. Part 1:
Nonsuicidal crisis callers. Suicide Life Threat Behav. 2007;37(3):322-337.
115. Gould MS, Kalafat J, Harrismunfakh JL, Kleinman M. An evaluation of crisis hotline outcomes.
Part 2: Suicidal callers. Suicide Life Threat Behav. 2007;37(3):338-352.
116. Chandler MJ, Lalonde CE. Cultural continuity as a moderator of suicide risk among Canada’s
First Nations. In: Kirmayer L, Valaskakis G, eds. The mental health of Canadian aboriginal peoples:
transformations, identity and community. Vancouver, Canada: University of British Columbia
Press; 2008:221-248.
117. Garroutte EM, Goldberg J, Beals J, Herrell R, Manson SM. Spirituality and attempted suicide
among American Indians. Soc Sci Med. 2003;56(7):1571-1579.
118. Centers for Disease Control and Prevention. Alcohol and suicide among racial/ethnic populations
– 17 states, 2005-2006. MMWR Morb Mortal Wkly Rep. 2009;58(23):637-641.
119. Walls ML, Chapple CL, Johnson KD. Strain, emotion and suicide among American Indian youth.
Deviant Behav. 2007;28(3):219-246.
120. Yoder KA, Whitbeck LB, Hoyt DR, LaFromboise T. Suicidal ideation among American Indian
youths. Arch Suicide Res. 2006;10(2):177-190.
121. Mock CN, Grossman DC, Mulder D, Stewart C, Koepsell TS. Health care utilization as a marker
for suicidal behavior on an American Indian Reservation. J Gen Intern Med. 1996;11(9):519-524.
122. Freedenthal S, Stiffman AR. “They might think I was crazy”: young American Indians’ reasons for
not seeking help when suicidal. J Adolesc Res. 2007;22(1):58-77.
123. Brave Heart MY, DeBruyn LM. The American Indian holocaust: healing historical unresolved
grief. Am Indian Alsk Native Ment Health Res. 1998;8(2):56-78.
124. U.S. Department of Health and Human Services. To live to see the great day that dawns: preventing
suicide by American Indian and Alaska Native youth and young adults. Rockville, MD: Substance
Abuse and Mental Health Services Administration; 2010.
125. Centers for Disease Control and Prevention. Adverse Childhood Experiences (ACE) Study.
Atlanta, GA: National Center for Chronic Disease Prevention and Health Promotion, Division of
Population Health; 2011. Available at www.cdc.gov/ace/index.htm. Accessed June 1, 2011.
PAGE 172
2012 NATIONAL STRATEGY FOR SUICIDE PREVENTION
126. Bender E. APA, AACAP suggest ways to reduce high suicide rates in Native Americans. Psychiatr
News. 2006;41(12):6.
127. U.S. Census Bureau. The American Indian and Alaska Native population: 2010. 2010 Census
Briefs. Author; January 2012. Available at www.census.gov/prod/cen2010/briefs/c2010br-10.pdf.
Accessed August 30, 2012.
128. Urban Indian Health Institute. Urban American Indian and Alaska Native Youth: an analysis of
select national data sources. Seattle, WA: Seattle Indian Health Board; 2009.
129. Johnson T, Tomren H. Helplessness, hopelessness, and despair: identifying the precursors to
Indian youth suicide. Am Indian Cult Res J. 1999;23(3):287-301.
130. LaFromboise T, Howard-Pitney B. The Zuni life skills development curriculum: description and
evaluation of a suicide prevention program. J Couns Psychol. 1995;42(4):479-486.
131. Carter SL, Straits JE, Hall M. Project Venture: Evaluation of a positive, culture-based approach
to substance abuse prevention with American Indian youth. Gallup, NM: Technical Report. The
National Indian Youth Leadership Project; 2007.
132. Mullany B, Barlow A, Goklish N, et al. Toward understanding suicide among youths: results from
the White Mountain Apache tribally mandated suicide surveillance system, 2001–2006. Am J
Public Health. 2009;99(10):1840-1848.
133. Cwik MF, Barlow A, Tingey L, Larzelere-Hinton F, Goklish N, Walkup JT. Nonsuicidal self-
injury in an American Indian reservation community: results from the White Mountain Apache
surveillance system, 2007-2008. J Am Acad Child Adolesc Psychiatry. 2011;50(9):860-869.
134. Crosby AE, Sacks JJ. Exposure to suicide: incidence and association with suicidal ideation and
behavior: United States, 1994. Suicide Life Threat Behav. 2002;32(3):321-328.
135. Berman A. Estimating the population of survivors of suicide: Seeking an evidence base. Suicide
Life Threat Behav. 2011;41(1):110-116.
136. McMenamy JM, Jordan JR, Mitchell AM. What do suicide survivors tell us they need? Results of a
pilot study. Suicide Life Threat Behav. 2008;38(4):375-389.
137. U.S. Department of Justice. Juvenile suicide in confinement: a national survey. Washington, DC:
Office of Juvenile Justice and Delinquency Prevention; 2009.
138. Memory J. Juvenile suicides in secure detention facilities: correction of published rates. Death
Stud. 1989;13:455-463.
139. Alessi NE, McManus M, Brickman A, Grapentine L. Suicidal behavior among serious juvenile
offenders. Am J Psychiatry. 1984;141(2):286-287.
PAGE 173
2012 NATIONAL STRATEGY FOR SUICIDE PREVENTION
140. Brent DA. Risk factors for adolescent suicide and suicidal behavior: mental and substance
abuse disorders, family environmental factors, and life stress. Suicide Life Threat Behav.
1995;25 Suppl:52-63.
141. Gray D, Achilles J, Keller T, et al. Utah youth suicide study, phase I: government agency contact
before death. J Am Acad Child Adolesc Psychiatry. 2002;41(4):427-434.
142. Hayes LM. Juvenile suicide in confinement—findings from the first national survey. Suicide Life
Threat Behav. 2009;39(4):353-363.
143. Rohde P, Seeley JR, Mace DE. Correlates of suicidal behavior in a juvenile detention population.
Suicide Life Threat Behav. 1997;27(2):164-175.
144. Parent D, Leiter V, Kennedy S, Livens L, Wentworth D, Wilcox S. Conditions of confinement:
juvenile detention and corrections facilities. Washington, DC: Office of Juvenile Justice and
Delinquency Prevention, U.S. Department of Justice; 1994.
145. Esposito CL, Clum GA. Social support and problem-solving as moderators of the relationship
between childhood abuse and suicidality: applications to a delinquent population. J Trauma
Stress. 2002;15(2):137-146.
146.
Hayes L. National study of jail suicide: 20 years later. Washington, DC: National Institute of
Corrections, US Department of Justice; 2010.
147. Wasserman GA, Jensen PS, Ko SJ, et al. Mental health assessments in juvenile justice: report on the
consensus conference. J Am Acad Child Adolesc Psychiatry. 2003;42(7):752-761.
148. Pilnik L. Youth suicide and self-harm: what advocates need to know. Child Law Practice.
June 2008;27(4):53-59.
149. Suicide Prevention Resource Center. Suicide prevention in juvenile correctional facilities: a
curriculum for state agency directors. Newton, MA: Education Development Center, Inc.; 2008.
150. Nock MK, Favazza AR. Nonsuicidal self-injury: definition and classification. In: Nock MK,
ed. Understanding nonsuicidal self-injury: origins, assessment, and treatment. Washington, DC:
American Psychological Association; 2009:9-18.
151. Hawton K, Zahl D, Weatherall R. Suicide following deliberate self-harm: long-term follow-up of
patients who presented to a general hospital. Br J Psychiatry. 2003;182:537-542.
152. Carter G, Reith DM, Whyte IM, McPherson M. Repeated self-poisoning: increasing severity of
self-harm as a predictor of subsequent suicide. Br J Psychiatry. 2005;186:253-257.
153. Owens D, Horrocks J, House A. Fatal and non-fatal repetition of self-harm. Systematic review. Br J
Psychiatry. 2002;181:193-199.
154. Brausch AM, Gutierrez PM. Differences in non-suicidal self-injury and suicide attempts in
adolescents. J Youth Adolesc. 2010;39(3):233-242.
PAGE 174
2012 NATIONAL STRATEGY FOR SUICIDE PREVENTION
155. Beautrais AL. Further suicidal behavior among medically serious suicide attempters. Suicide Life
Threat Behav. 2004;34(1):1-11.
156. Monti K, Cedereke M, Ojehagen A. Treatment adherence and suicidal behavior 1 month
and 3 months after a suicide attempt: a comparison between two samples. Arch Suicide
Res. 2003;7(2):167-174.
157. Cedereke M, Ojehagen A. Patients’ needs during the year after a suicide attempt. A
secondary analysis of a randomised controlled intervention study. Soc Psychiatry Psychiatr
Epidemiol. 2002;37(8):357-363.
158. Liberman RP. Follow-up for parasuicidal patients. Psychiatr Serv. 2001;52(9):1254.
159. Motto JA, Bostrom AG. A randomized controlled trial of postcrisis suicide prevention. Psychiatr
Serv. 2001;52:828-833.
160. Litts D, Beautrais A, Lezine DQ. First national conference for survivors of suicide attempts, health
care professionals, and clergy and laity: Summary of workgroup reports. Newton, MA: Suicide
Prevention Resource Center; 2008. Available at www.sprc.org/library/SOSAconf.pdf. Accessed
August 30, 2012.
161. Macro International. Lifeline service and outreach strategies suggested by suicide attempt survivors:
final report of the Attempt Survivor Advisory Summit Meeting and individual interviews. Rockville,
MD: National Suicide Prevention Lifeline; 2007.
162. Substance Abuse and Mental Health Services Administration. Consumer-operated services:
the evidence. HHS Pub. No. SMA-11-4633, Rockville, MD: Center for Mental Health Services,
Substance Abuse and Mental Health Services Administration, U.S. Department of Health and
Human Services; 2011.
163. National Cancer Institute. PDQ depression: suicide risk in cancer patients. Bethesda, MD:
National Cancer Institute; 2011. Available at www.cancer.gov/cancertopics/pdq/supportivecare/
depression/HealthProfessional/page4. Accessed June 30, 2011.
164. Lonnqvist JK. Physical illness and suicide. In: Wasserman D, ed. Suicide: an unnecessary death.
London: Martin Dunitz; 2001:93-98.
165. DeLeo D, Meneghel G. The elderly and suicide. In: Wasserman D, ed. Suicide: an unnecessary
death. London: Martin Dunitz; 2001:195-207.
166. Schlebusch L. Suicide risk and cancer. In: Berman AL, Pompili M, eds. Medical conditions
associated with suicide risk. Washington, DC: American Association of Suicidology; 2011:59-74.
167. National Cancer Institute. PDQ depression: assessment, evaluation, and management of
suicidal patients. Bethesda, MD: National Cancer Institute; 2011. Available at www.cancer.gov/
cancertopics/pdq/supportivecare/depression/HealthProfessional/page5. Accessed June 30, 2011.
PAGE 175
2012 NATIONAL STRATEGY FOR SUICIDE PREVENTION
168. Akechi T, Ietsugu T, Sukigara M, et al. Symptom indicator of severity of depression in cancer
patients: a comparison of the DSM-IV criteria with alternative diagnostic criteria. Gen Hosp
Psychiatry. 2009;31(3):225-232.
169. Huntington G. On chorea. George Huntington, M.D. J Neuropsychiatry Clin
Neurosci. 2003;15(1):109-112.
170. Fiedorowicz JG, Ruggle A, Paulsen JS. Suicide and Huntington disease. In: Berman AL, Pompili
M, eds. Medical conditions associated with suicide risk. Washington, DC: American Association of
Suicidology; 2011:173-186.
171. Stenager EN, Stenager E, Koch-Henriksen N, et al. Suicide and multiple sclerosis: an
epidemiological investigation. J Neurol Neurosurg Psychiatry. 1992;55(7):542-545.
172. Samuel LS. Suicide and multiple sclerosis. In: Berman AL, Pompili M, eds. Medical conditions
associated with suicide risk. Washington, DC: American Association of Suicidology; 2011:207-214.
173. Weintraub D, Stern MB. Psychiatric complications in Parkinson disease. Am J Geriatr
Psychiatry. 2005;13(10):844-851.
174. Raja M. Suicide in Parkinson’s disease. In: Berman AL, Pompili M, eds. Medical conditions
associated with suicide risk. Washington, DC: American Association of Suicidology; 2011:215-228.
175. Hartkopp A, Bronnum-Hansen H, Seidenschnur AM, Biering-Sorensen F. Suicide
in a spinal cord injured population: its relation to functional status. Arch Phys Med
Rehabil. 1998;79(11):1356-1361.
176. Kennedy P, Rogers B, Speer S, Frankel H. Spinal cord injuries and attempted suicide: a
retrospective review. Spinal Cord. 1999;37(12):847-852.
177. Hatcher MB, Whitaker C, Karl A. What predicts post-traumatic stress following spinal cord
injury? Br J Health Psychol. 2009;14(Pt 3):541-561.
178. Lezak MD, Howieson DB, Loring DL, eds. Neuropsychological assessment. 4th ed. New York:
Oxford University Press; 2004.
179. Jollant F, Bellivier F, Leboyer M, et al. Impaired decision making in suicide attempters. Am J
Psychiatry. 2005;162(2):304-310.
180. Simpson G, Tate R. Suicidality in people surviving a traumatic brain injury: prevalence, risk
factors and implications for clinical management. Brain Inj. 2007;21(13-14):1335-1351.
181. Jallon P. Mortality in patients with epilepsy. Curr Opin Neurol. 2004;17(2):141-146.
182. Mendez MF, Doss RC. Ictal and psychiatric aspects of suicide in epileptic patients. Int J Psychiatry
Med. 1992;22(3):231-237.
183. Blumer D, Montouris G, Davies K, Wyler A, Phillips B, Hermann B. Suicide in epilepsy:
psychopathology, pathogenesis, and prevention. Epilepsy Behav. 2002;3(3):232-241.
PAGE 176
2012 NATIONAL STRATEGY FOR SUICIDE PREVENTION
184. Janz D. Die epilepsien: spezielle pathologie und therapie. Stuttgart: George Thieme; 1969.
185. World Health Organization. Preventing suicide: a resource for primary health care workers. Geneva:
WHO; 2000.
186. Amoozegar F, St. Germaine C, Becker WJ, Jette N. Suicide and migraines and chronic headaches.
In: Berman AL, Pompili M, eds. Medical conditions associated with suicide risk. Washington, DC:
American Association of Suicidology; 2011:193-205.
187. Cooperman NA. HIV/AIDS and suicide. In: Berman AL, Pompili M, eds. Medical conditions
associated with suicide risk. Washington, DC: American Association of Suicidology; 2011:159-171.
188. Goodwin RD, Marusic A, Hoven CW. Suicide attempts in the United States: the role of physical
illness. Soc Sci Med. 2003;56(8):1783-1788.
189. Malbergier A, de Andrade AG. Depressive disorders and suicide attempts in injecting drug users
with and without HIV infection. AIDS Care. 2001;13(1):141-150.
190. Grassi L, Mondardini D, Pavanati M, Sighinolfi L, Serra A, Ghinelli F. Suicide probability and
psychological morbidity secondary to HIV infection: a control study of HIV-seropositive,
hepatitis C virus (HCV)-seropositive and HIV/HCV-seronegative injecting drug users. J Affect
Disord. 2001;64(2-3):195-202.
191. Starace F, Sherr L. Suicidal behaviours, euthanasia and AIDS. AIDS. 1998;12(4):339-347.
192. Bellini M, Bruschi C. HIV infection and suicidality. J Affect Disord. 1996;38(2-3):153-164.
193. Kimmel PL, Cukor D, Cohen SD, Peterson RA. Depression in end-stage renal disease patients: a
critical review. Adv Chronic Kidney Dis. 2007;14(4):328-334.
194. Cukor D, Peterson RA, Cohen SD, Kimmel PL. Depression in end-stage renal disease hemodialysis
patients. Nat Clin Pract Nephrol. 2006;2(12):678-687.
195. Stang PE, Brandenburg NA, Lane MC, Merikangas KR, Von Korff MR, Kessler RC. Mental
and physical comorbid conditions and days in role among persons with arthritis. Psychosom
Med. 2006;68(1):152-158.
196. McWilliams LA, Clara IP, Murphy PD, Cox BJ, Sareen J. Associations between arthritis and
a broad range of psychiatric disorders: findings from a nationally representative sample. J
Pain. 2008;9(1):37-44.
197. He Y, Zhang M, Lin EH, et al. Mental disorders among persons with arthritis: results from the
World Mental Health Surveys. Psychol Med. 2008;38(11):1639-1650.
198. Brennenstuhl S, Shaked Y, Fuller-Thomson E. Suicide risk and cancer. In: Berman AL, Pompili
M, eds. Medical conditions associated with suicide risk. Washington, DC: American Association of
Suicidology; 2011:27-38.
PAGE 177
2012 NATIONAL STRATEGY FOR SUICIDE PREVENTION
199. Kuo CJ, Chen VC, Lee WC, et al. Asthma and suicide mortality in young people: a 12-year follow-
up study. Am J Psychiatry. 2010;167(9):1092-1099.
200. Goodwin RD, Marusic A. Asthma and suicidal ideation among youth in the community.
Crisis. 2004;25(3):99-102.
201. Goodwin RD, Olfson M, Shea S, et al. Asthma and mental disorders in primary care. Gen Hosp
Psychiatry. 2003;25(6):479-483.
202. Goodwin FK, Jamison KR. Manic-depressive illness: bipolar disorders and recurrent depression. New
York: Oxford University Press; 2007.
203. Rihmer Z, Angst J. Epidemiology of bipolar disorders. In: Kasper S, Hirschfeld RMA, eds.
Handbook of bipolar disorders. New York: Taylor & Francis; 2005:21-35.
204. Abreu LN, Lafer B, Baca-Garcia E, Oquendo MA. Suicidal ideation and suicide attempts in bipolar
disorders type I: an update for the clinician. Rev Bras Psiquiatr. 2009;31(3):271-280.
205. Rihmer Z. Depression and suicidal behavior. In: O’Connor R, Plat S, Gordon J, eds. International
handbook of suicide prevention: research, policy, and practice. West Sussex, UK: John Wiley &
Sons; 2011.
206. Bolton JM, Pagura J, Enns MW, Grant B, Sareen J. A population-based longitudinal study of risk
factors for suicide attempts in major depressive disorder. J Psychiatr Res. 2010;44(13):817-826.
207. Hawton K, Sutton L, Haw C, Sinclair J, Harriss L. Suicide and attempted suicide in bipolar
disorders: a systematic review of risk factors. J Clin Psychiatry. 2005;66(6):693-704.
208. Hu G, Wilcox HC, Wissow L, Baker SP. Mid-life suicide: an increasing problem in U.S. Whites,
1999-2005. Am J Prev Med. 2008;35(6):589-593.
209. Kessler RC, Chiu WT, Demler O, Merikangas KR, Walters EE. Prevalence, severity, and
comorbidity of 12-month DSM-IV disorders in the National Comorbidity Survey Replication.
Arch Gen Psychiatry. 2005;62(6):617-627.
210. Sareen J, Cox BJ, Afifi TO, et al. Anxiety disorders and risk for suicidal ideation
and suicide attempts: a population-based longitudinal study of adults. Arch Gen
Psychiatry. 2005;62(11):1249-1257.
211. Nepon J, Belik SL, Bolton J, Sareen J. The relationship between anxiety disorders and suicide
attempts: findings from the National Epidemiologic Survey on Alcohol and Related Conditions.
Depress Anxiety. 2010;27(9):791-798.
212. Soloff PH, Lynch KG, Kelly TM, Malone KM, Mann JJ. Characteristics of suicide attempts of
patients with major depressive episode and borderline personality disorder: a comparative study.
Am J Psychiatry. 2000;157(4):601-608.
PAGE 178
2012 NATIONAL STRATEGY FOR SUICIDE PREVENTION
213. Paris J. Personality disorders and suicidal behavior. In: Connor RC, Platt S, Gordon J, eds.
International handbook of suicide prevention: research, policy and prevention. West Sussex, UK:
John Wiley & Sons; 2011:109-118.
214. Paris J. Personality disorders over time. Washington, DC: American Psychiatric Press, Inc.; 2003.
215. Paris J. Clinical trials of treatment for personality disorders. Psychiatr Clin North Am.
2008;31(3):517-526, viii.
216. Amador X. Understanding and assessing insight. In: Amador X, David A, eds. Insight and
psychosis. 2nd ed. New York: Oxford University Press; 2004.
217. Hogarty GE, Flesher S, Ulrich R, et al. Cognitive enhancement therapy for schizophrenia: effects
of a 2-year randomized trial on cognition and behavior. Arch Gen Psychiatry. 2004;61(9):866-876.
218. Centers for Disease Control and Prevention. Suicides due to alcohol and/or drug overdose:
a data brief from the National Violent Death Reporting System. Available at www.cdc.gov/
ViolencePrevention/NVDRS/nvdrs_data_brief.html. Accessed December 22, 2011.
219. Skog O-J. Alcohol and suicide—Durkheim revisited. Acta Sociol. 1991;34(3):193-206.
220. Conner KR, Duberstein PR. Predisposing and precipitating factors for suicide among alcoholics:
empirical review and conceptual integration. Alcohol Clin Exp Res. 2004;28(5 Suppl):6S-17S.
221. Mościcki EK. Epidemiology of completed and attempted suicide: toward a framework for
prevention. Clin Neurosci Res. 2001;1(5):310-323.
222. Cherpitel CJ, Borges GL, Wilcox HC. Acute alcohol use and suicidal behavior: a review of the
literature. Alcohol Clin Exp Res. 2004;28(5 Suppl):18S-28S.
223. McKeon RT. Suicidal behavior. Toronto, Ontario, Canada: Hogrefe & Huber; 2009.
224. Conner KR, Duberstein PR, Conwell Y. Age-related patterns of factors associated with completed
suicide in men with alcohol dependence. Am J Addict. 1999;8(4):312-318.
225. Cheng AT. Mental illness and suicide. A case-control study in east Taiwan. Arch Gen
Psychiatry. 1995;52(7):594-603.
226. Substance Abuse and Mental Health Services Administration. Substance abuse and suicide
prevention: evidence & implications—a white paper. HHS Publication No. (SMA) 08-4352.
Rockville, MD: Substance Abuse and Mental Health Services Administration; 2008.
227. Ilgen MA, Harris AH, Moos RH, Tiet QQ. Predictors of a suicide attempt one year after entry into
substance use disorder treatment. Alcohol Clin Exp Res. 2007;31(4):635-642.
228. Wilcox HC, Conner KR, Caine ED. Association of alcohol and drug use disorders and completed
suicide: an empirical review of cohort studies. Drug Alcohol Depend. 2004;76 Suppl:S11-19.
229. Mathy RM. Suicidality and sexual orientation in five continents: Asia, Australia, Europe, North
America, and South America. Int J Sex Gend Stud. 2002;7(2-3):215-225.
PAGE 179
2012 NATIONAL STRATEGY FOR SUICIDE PREVENTION
230. King M, Semlyen J, Tai SS, et al. A systematic review of mental disorder, suicide, and deliberate self
harm in lesbian, gay and bisexual people. BMC Psychiatry. 2008;8:70.
231. Grant JM, Mottet LA, Tanis J, Harrison J, Herman JL, Keisling M. Injustice at every turn: a
report of the National Transgender Discrimination Survey. Washington, DC: National Center for
Transgender Equality and National Gay and Lesbian Task Force; 2011.
232. Russell ST, Toomey RB. Men’s sexual orientation and suicide: evidence for U.S. adolescent-specific
risk. Soc Sci Med. 2012;74(4):523-529.
233. Remafedi G. Suicidality in a venue-based sample of young men who have sex with men. J Adolesc
Health. 2002;31(4):305-310.
234. Paul JP, Catania J, Pollack L, et al. Suicide attempts among gay and bisexual men: lifetime
prevalence and antecedents. Am J Public Health. 2002;92(8):1338-1345.
235. Meyer IH, Dietrich J, Schwartz S. Lifetime prevalence of mental disorders and suicide attempts in
diverse lesbian, gay, and bisexual populations. Am J Public Health. 2008;98(6):1004-1006.
236. Meyer IH. Prejudice, social stress, and mental health in lesbian, gay, and bisexual populations:
conceptual issues and research evidence. Psychol Bull. 2003;129(5):674-697.
237. Hatzenbuehler ML, Keyes KM, Hasin DS. State-level policies and psychiatric morbidity in lesbian,
gay, and bisexual populations. Am J Public Health. 2009;99(12):2275-2281.
238. Hatzenbuehler ML, McLaughlin KA, Keyes KM, Hasin DS. The impact of institutional
discrimination on psychiatric disorders in lesbian, gay, and bisexual populations: a prospective
study. Am J Public Health. 2010;100(3):452-459.
239. Ryan C, Russell ST, Huebner D, Diaz R, Sanchez J. Family acceptance in adolescence and the
health of LGBT young adults. J Child Adolesc Psychiatr Nurs. 2010;23(4):205-213.
240. Blosnich JR, Bossarte RM, Silenzio VM. Suicidal ideation among sexual minority veterans: results
from the 2005-2010 Massachusetts behavioral risk factor surveillance survey. Am J Public Health.
2012;102 Suppl 1:S44-47.
241. Movement Advancement Project (MAP). Talking about suicide & LGBT populations. Author; 2011.
Available at: www.lgbtmap.org/talking-about-suicide-and-lgbt-populations. Accessed August
30, 2012.
242. US Army Medical System and Materiel Command, Medical Mortality Surveillance Division.
Armed Forces Medical Examiner System: Data reported as of May 26th, 2011.
243. U.S.
Army. Army health promotion risk reduction suicide prevention report 2010. Available at
http://csf.army.mil/downloads/HP-RR-SPReport2010.pdf. Accessed August 30, 2012.
PAGE 180
2012 NATIONAL STRATEGY FOR SUICIDE PREVENTION
244. U.S. Department of Defense. Department of Defense suicide event report (DoDSER): calendar year
2010 annual report. National Center for Telehealth and Technology, Defense Centers of Excellence
for Psychological Health & Traumatic Brain Injury; 2011.
245. Karch DL, Dahlberg LL, Patel N, et al. Surveillance for violent deaths—national violent death
reporting system, 16 States, 2006. MMWR Surveill Summ. 2009;58(1):1-44.
246. Kaplan MS, Huguet N, McFarland BH, Newsom JT. Suicide among male veterans: a prospective
population-based study. J Epidemiol Community Health. 2007;61(7):619-624.
247. Miller M, Barber C, Azrael D, Calle EE, Lawler E, Mukamal KJ. Suicide among U.S. veterans: a
prospective study of 500,000 middle-aged and elderly men. Am J Epidemiol. 2009;170(4):494-500.
248. Veterans Health Administration. Administrative records and Internal briefings: Department of
Veterans Affairs.
249. McCarthy JF, Valenstein M, Kim HM, Ilgen M, Zivin K, Blow FC. Suicide mortality
among patients receiving care in the veterans health administration health system. Am J
Epidemiol. 2009;169(8):1033-1038.
250. Ilgen MA, Bohnert AS, Ignacio RV, et al. Psychiatric diagnoses and risk of suicide in veterans. Arch
Gen Psychiatry. 2010;67(11):1152-1158.
251. Watanabe KK, Kang HK. Mortality patterns among Vietnam veterans: a 24-year retrospective
analysis. J Occup Environ Med. 1996;38(3):272-278.
252. Veterans Health Administration. Uniform mental health services in VA medical centers and
clinics. Handbook 1160.01: Department of Veterans Affairs; 2008. Available at www.va.gov/
vhapublications/ViewPublication.asp?pub_ID=1762. Accessed August 30, 2012.
253. Hu G, Wilcox HC, Wissow L, Baker SP. Mid-life suicide: an increasing problem in U.S. Whites,
1999-2005. Am J Prev Med. 2008;35(6):589-593.
254. Caine ED, Knox KL, Conwell Y. Public health and population approaches for suicide prevention.
In: Cohen NL, Galea, S., ed. Population mental health: evidence, policy, & public health practice.
London & New York: Routledge; 2011:303-338.
255. Knox K, Caine E. Establishing priorities for reducing suicide and its antecedents in the United
States. Am J Public Health. 2005;95(11):1898-1903.
256. Oliffe JL, Phillips MJ. Men, depression and masculinities: A review and recommendations. J Mens
Health. 2008;5(3):194-202.
257. Addis ME, Mahalik JR. Men, masculinity, and the contexts of help seeking. Am
Psychol. 2003;58(2):5-14.
258. Conner KR, Cox C, Duberstein PR, Tian L, Nisbet PA, Conwell Y. Violence, alcohol, and
completed suicide: a case-control study. Am J Psychiatry. 2001;158:1701-1705.
PAGE 181
2012 NATIONAL STRATEGY FOR SUICIDE PREVENTION
259. Barth A, Sogner L, Gnambs T, Kundi M, Reiner A, Winker R. Socioeconomic factors and suicide:
An analysis of 18 industrialized countries for the years 1983 through 2007. J Occup Environ
Med. 2011;53(3):313-317.
260. Knox K, Litts D, Talcott G, Feig J, Caine E. Risk of suicide and related adverse outcomes
after exposure to a suicide prevention programme in the US Air Force: cohort study.
BMJ. 2003;327(7428):1376.
261. Knox KL, Pflanz S, Talcott GW, et al. The US Air Force Suicide Prevention Program: implications
for public health policy. Am J Public Health. 2010;100(12):2457-2463.
262. Gullestrup J, Lequertier B, Martin G. MATES in construction: impact of a multimodal,
community-based program for suicide prevention in the construction industry. Int J of Environ
Res Public Health. 2011;8(11):4180-4196.
263. Nakao M, Nishikitani M, Shima S, Yano E. A 2-year cohort study on the impact of an Employee
Assistance Programme (EAP) on depression and suicidal thoughts in male Japanese workers. Int
Arch Occup Environ Health. 2007;81(2):151-157.
264. Conwell Y, Duberstein PR, Connor K, Eberly S, Cox C, Caine ED. Access to firearms and risk for
suicide in middle-aged and older adults. Am J Geriatr Psychiatry. 2002;10(4):407-416.
265. Mann JJ, Apter A, Bertolote J, et al. Suicide prevention strategies. JAMA. 2005;294(16):2064-2074.
266. Kellam SG, Brown CH, Poduska JM, et al. Effects of a universal classroom behavior management
program in first and second grades on young adult behavioral, psychiatric, and social outcomes.
Drug Alcohol Depend. 2008;95 Suppl 1:S5-S28.
267. Conwell Y, Thompson C. Suicidal behavior in elders. Psychiatr Clin North Am. 2008;31(2):333-356.
268. Conwell Y, Duberstein PR, Cox C, Herrmann J, Forbes N, Caine ED. Age differences in behaviors
leading to completed suicide. Am J Geriatr Psychiatry. 1998;6(2):122-126.
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